Physical Therapy- Journal of the APTA, Volume 90, Issue 7 (July 2010)

July 2010  Volume 90  Number 7

Research Reports

Focus on the ICF

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Energy Cost of Walking in Older Adults

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986

Muscle Activation Patterns During Walking in Children

Application of the ICF in Multidisciplinary Patient Management

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Creating an Interface Between the ICF and Physical Therapist Practice

1001

Physical Activity in Multiple Sclerosis

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Facilitators and Barriers to Exercise in People With Osteoarthritis

1026

Competence Assessment in Physical Therapy

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Perspective 1068

Ethics Knowledge and Practice in Physical Therapy

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Physical Therapy Journal of the American Physical Therapy Association

Editorial Office

Editor in Chief

Managing Editor / Associate Director of Publications: Jan P. Reynolds, [email protected]

Rebecca L. Craik, PT, PhD, FAPTA, Philadelphia, PA [email protected]

PTJ Online Editor / Assistant Managing Editor: Steven Glaros Associate Editor: Stephen Brooks, ELS Production Manager: Liz Haberkorn

Deputy Editor in Chief Daniel L. Riddle, PT, PhD, FAPTA, Richmond, VA

Editor in Chief Emeritus Jules M. Rothstein, PT, PhD, FAPTA (1947–2005)

Steering Committee

Permissions / Reprint Coordinator: Michele Tillson

Anthony Delitto, PT, PhD, FAPTA (Chair), Pittsburgh, PA; J. Haxby Abbott, PhD, MScPT, DipGrad, FNZCP, Dunedin, New Zealand; Joanell Bohmert, PT, MS, Mahtomedi, MN; Alan M. Jette, PT, PhD, FAPTA, Boston, MA; Charles Magistro, PT, FAPTA, Claremont, CA; Ruth B. Purtilo, PT, PhD, FAPTA, Boston, MA; Julie Whitman, PT, DSc, OCS, Westminster, CO

Advertising Manager: Julie Hilgenberg

Editorial Board

Manuscripts Coordinator: Karen Darley

Director of Publications: Lois Douthitt

APTA Executive Staff Vice President for Communications: Felicity Feather Clancy Chief Financial Officer: Rob Batarla Chief Executive Officer: John D. Barnes

Advertising Sales Ad Marketing Group, Inc 2200 Wilson Blvd, Suite 102-333 Arlington, VA 22201 703/243-9046, ext 102

Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia; W. Todd Cade, PT, PhD, St. Louis, MO; James Carey, PT, PhD, Minneapolis, MN; John Childs, PT, PhD, Schertz, TX; Charles Ciccone, PT, PhD, FAPTA (Continuing Education), Ithaca, NY; Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT, Concord, NH; Janice J. Eng, PT/OT, PhD, Vancouver, BC, Canada; James C. (Cole) Galloway, PT, PhD, Newark, DE; Steven Z. George, PT, PhD, Gainesville, FL; Kathleen Gill-Body, PT, DPT, NCS, Boston, MA; Paul J.M. Helders, PT, PhD, PCS, Utrecht, The Netherlands; Maura D. Iversen, PT, ScD, MPH, Boston, MA; Diane U. Jette, PT, DSc, Burlington, VT; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Christopher J. Main, PhD, FBPsS, Keele, United Kingdom; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; Patricia Ohtake, PT, PhD, Buffalo, NY; Carolynn Patten, PT, PhD, Gainesville, FL; Linda Resnik, PT, PhD, OCS, Providence, RI; Kathleen Sluka, PT, PhD, Iowa City, IA; Patty Solomon, PT, PhD, Hamilton, Ont, Canada

Statistical Consultants

President / Advertising Account Manager: Jane Dees Richardson

Steven E. Hanna, PhD, Hamilton, Ont, Canada; John E. Hewett, PhD, Columbia, MO; Hang Lee, PhD, Boston, MA; Xiangrong Kong, PhD, Baltimore, MD; Paul Stratford, PT, MSc, Hamilton, Ont, Canada; Samuel Wu, PhD, Gainesville, FL

Board of Directors

Committee on Health Policy and Ethics

President: R. Scott Ward, PT, PhD

Linda Resnik, PT, PhD, OCS (Chair), Providence, RI; Janet Freburger, PT, PhD, Chapel Hill, NC; Alan Jette, PT, PhD, FAPTA, Boston, MA; Michael Johnson, PT, PhD, OCS, Philadelphia, PA; Justin Moore, PT, DPT, Alexandria, VA; Ruth Purtilo, PT, PhD, FAPTA, Boston, MA

Vice President: Paul A. Rockar Jr, PT, DPT, MS Secretary: Babette S. Sanders, PT, MS Treasurer: Connie D. Hauser, PT, DPT, ATC Speaker of the House: Shawne E. Soper, PT, DPT, MBA Vice Speaker of the House: Laurita M. Hack, PT, DPT, MBA, PhD, FAPTA Directors: Sharon L. Dunn, PT, PhD, OCS; Kevin L. Hulsey, PT, DPT, MA; Dianne V. Jewell, PT, DPT, PhD, CCS, FAACVPR; Aimee B. Klein, PT, DPT, DSc, OCS; Kathleen K. Mairella, PT, DPT, MA; Stephen C.F. McDavitt, PT, DPT, MS, FAAOMPT; Lisa K. Saladin, PT, PhD; Mary C. Sinnott, PT, DPT, MEd; Nicole L. Stout, PT, MPT, CLT-LANA

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Linking Evidence And Practice Advisory Group Rachelle Buchbinder, MBBS(Hons), MSc, PhD, FRACP, Malvern, Victoria, Australia (Co-Chair); Diane U. Jette, PT, DSc, Burlington, VT (Co-Chair); W. Todd Cade, PT, PhD, St. Louis, MO; Christopher Maher, PT, PhD, Lidcombe, NSW, Australia; Kathleen Kline Mangione, PT, PhD, GCS, Philadelphia, PA; David Scalzitti, PT, PhD, OCS, Alexandria, VA

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Subscriptions

Physical Therapy (PTJ) (ISSN 00319023) is published monthly by the American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA 22314-1488, at an annual subscription rate of $12 for members, included in dues. Nonmember rates are as follows: Individual (inside USA)— $99; individual (outside USA)—$119 surface mail, $179 air mail. Institutional (inside USA)—$129; institutional (outside USA)—$149 surface mail, $209 air mail. Periodical postage is paid at Alexandria, VA, and at additional mailing offices. Postmaster: Send address changes to Physical Therapy, 1111 North Fairfax Street, Alexandria, VA 22314-1488. Single copies: $15 USA, $15 outside USA; with the exception of January 2001: $50 USA, $70 outside USA. All orders payable in US currency. No replacements for nonreceipt after a 3-month period has elapsed. Canada Post International Publications Mail Product Sales Agreement No. 0055832.

Members and Subscribers Send changes of address to: APTA, Attn: Membership Dept, 1111 North Fairfax St, Alexandria, VA 22314-1488. Subscription inquiries: 703/684-2782, ext 3124. PTJ is available in a special format for readers who are visually impaired. For information, contact APTA’s Membership Department at 703/684-2782, ext 3124.

Mission Statement

Physical Therapy (PTJ) engages and inspires an international readership on topics related to physical therapy. As the leading international journal for research in physical therapy and related fields, PTJ publishes innovative and highly relevant content for both clinicians and scientists and uses a variety of interactive approaches to communicate that content, with the expressed purpose of improving patient care.

Readers are invited to submit manuscripts to PTJ. PTJ’s content—including editorials, commentaries, letters, and book reviews—represents the opinions of the authors and should not be attributed to PTJ or its Editorial Board. Content does not reflect the official policy of APTA or the institution with which the author is affiliated, unless expressly stated.

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PTJ Online at ptjournal.apta.org

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PTJ Online is available via RSS feeds. PTJ posts articles ahead of print and rapid reader responses to articles. Articles, letters to the editor, and editorials are available in full text starting with Volume 79 (1999) and in searchable PDF format starting with Volume 60 (1980). Entire issues are available online beginning with Volume 86 (2006) and include additional data, video clips, and podcasts.

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Full-text articles are available for free at ptjournal.apta.org 12 months after the publication date. Full text also is provided through DataStar, Dialog, EBSCOHost Academic Search, Factiva, InfoTrac, ProFound, and ProQuest.

Readers should direct requests for reprints to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from this publication by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Authors who want reprints should contact June Billman, Cadmus Communications, at 800/4875625, or [email protected]. Nonacademic institutions needing reprint permission information should go to ptjournal.apta.org/misc/terms.dtl.

Advertising Advertisements are accepted by PTJ when they conform to the ethical standards of the American Physical Therapy Association. PTJ does not verify the accuracy of claims made in advertisements, and acceptance does not imply endorsement by PTJ or the Association. Acceptance of advertisements for professional development courses addressing advanced-level competencies in clinical specialty areas does not imply review or endorsement by the American Board of Physical Therapy Specialties.

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Editorial Physical Therapists in Post-Earthquake Haiti: Seeking a Balance Between Humanitarian Service and Research

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n January 12, 2010, a devastating earthquake measuring 7.0 on the Richter scale occurred in the small Caribbean nation of Haiti. Much of the instantaneous human and structural destruction that resulted from this massive earthquake was broadcast widely via media sources, and the world immediately responded. Within hours of the event, emergency medical teams joined the large number of nongovernmental organizations (NGOs) already operational in Haiti, and humanitarian aid began to flow into the capital of Port-au-Prince by land (through the Dominican Republic), air, and sea. More than 6 months following the event, many of the details remain “preliminary”; however, we know that at least 220,000 people died, making this earthquake one of the largest singleday casualty counts in history.1,2 Even though the number of fatalities is staggering, it is believed that mortality rates would have been higher if the international community had not responded so quickly.

Figure 1. Jamie Young, PT (left), and Tess Devji, OT (center), help a patient stand for the first time since the earthquake. (Photo Credit: Lisa Carnie)

Physical therapists from around the world have become part of the global response in Haiti. Although there are far too many individuals and organizations to mention here, collectively they have placed their personal and professional lives on hold in order to contribute to the global humanitarian efforts in this devastated country. These physical therapists are an inspirational group of caring people who have made, are making, and will make important contributions in Haiti. They also have indirectly helped to propel physical therapy into the mainstream of humanitarian aid and relief (Fig. 1). I have been fortunate to be involved as part of Toronto Rehabilitation Institute’s (TRI) humanitarian response in Haiti. The TRI has been working with partners from Healing Hands for Haiti at a spinal cord rehabilitation unit that emerged in the post-earthquake phase. Three main sites in Haiti agreed to admit people with spinal cord injuries following the earthquake: St. Boniface Hospital in Fond-des-Blanc, Medishare/University of Miami project in Port-au-Prince, and Haiti Hospital Appeal (HHA) in Cap-Haitien. The Toronto Rehabilitation Institute has been providing direct care and education to HHA for a number of weeks, and, in this editorial, I use some of these experiences to highlight and argue 2 concepts.

Decreased Mortality Results in Increased Morbidity

To comment, submit a Rapid Response to this editorial posted online at ptjournal.apta.org.

Preserving life clearly was the primary mission in the aftermath of this natural disaster, but the lives saved translated into a large population of people who will live with major lifelong disabilities. Relatively low mortality rates engender higher morbidity rates, and an estimated 300,000 people were injured during the earthquake. Estimates indicate that 2,000 to 4,000 people survived with amputations, more than 200 survived with spinal cord injuries (SCI), and thousands had fractures.3 From a rehabilitation perspective, one of the important outcomes of this earthquake is that it created a sizeable cohort of people with disabilities—which added to the already large number of Haitians living with disabilities. Even prior to the earthquake, from both a societal and a structural/architectural perspective, Haiti was a rather hostile environment for people with disabilities. The utter destruction that this earthquake caused in the affected zones has made accessibility and housing an even more critical issue (Fig. 2).

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Editorial I do not suggest for a moment that the decision to preserve life was incorrect; on the contrary, I admire and applaud the fine work of others in the acute phase of the disaster. Rather, I am signaling that the preservation of life—which results in a corresponding growth in cohorts of people with disabilities—demands the moral and ethical accountability of the international community to also provide appropriate rehabilitation services to ensure some level of quality of life for individuals in the post-earthquake period. Prior to the earthquake, for example, very few people in Haiti lived with SCI; however, due to lifesaving interventions after the earthquake, about 200 people with SCI have survived. Because of low prevalence rates prior to the earthquake, few settings in Haiti provided spinal cord rehabilitation; furthermore, the Haitian health care provider community had very little experience with such complex injuries. In fact, after the earthquake, a Haitian nurse colleague asked an insightful question: “What kind of earthquake happened in North America for you to develop all this expertise with these patients?” This question created a powerful context for our work. Spinal cord rehabilitation in North America began when soldiers returned home from World War II with SCI. We in North America have been developing expertise in the treatment of spinal injuries for close to 65 years; in Haiti, they have been developing their skills in the weeks since January 2010.

Figure 2. Collapsed and collapsing buildings define the landscape of Port-auPrince. (Photo credit: Landry)

I contend that if the global community intervenes to preserve lives following disasters, the nature of these situations creates a moral imperative to provide direct rehabilitation services and to train local providers to manage the complex outcomes.

We Need a Balance Between Humanitarian Service and Research It may seem premature to suggest the necessity for a research agenda, given that much suffering continues (almost unabated in some cases) across Haiti. However, questions must be asked in order to more fully understand the effects of the Haitian earthquake. There are 2 primary areas of scientific inquiry that, in my opinion, must be conducted in this context. The first line of inquiry is related to more fully exploring the types of injuries that occurred as a direct result of the earthquake. For example, establishing the clinical profiles of people who survived the earthquake and sustained SCI would provide important insights into the etiology and mechanism of injuries that occur in a disaster of this type. Given our experience with the HHA, we suspect that many of the people who survived with SCI are young (under 30 years old), have very few comorbidities, and have low thoracic or high lumbar lesions. We hypothesize that few individuals with cervical injuries survived and that only the healthiest could withstand the lengthy process of being triaged and subsequently transferred between multiple facilities across Haiti in the effort to reach appropriate care. The patient profile is likely to be different in Canada or the United States, and a comparative analysis would identify important differences and could be used to prepare for future emergency responses. For instance, prior to assessing Haitian patients with SCI, we assumed that pressure ulcers would be a priority area; however, upon our arrival, wounds (mostly stage IV) were being well managed, whereas bowel and bladder care was lacking—resulting in a vastly different clinical picture than we expected. Data to clarify these questions and observations could yield essential information to create an evidence-informed framework to consider for current and future emergency humanitarian rehabilitation responses. The second line of priority inquiry is related to discharge planning for people who survived the earthquake but who now live with major disabilities. Discharge planning in Haiti has been complicated by the destruction of the infrastructure—from individual homes to

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Editorial

Figure 3. Severe infrastructure damage has complicated discharge planning, especially among people with mobility impairments. (Photo credit: Landry)

facilities—and by the absence of many family members who have been displaced themselves or who died during the earthquake (Fig. 3). As of press time, the NGO community involved in long-term planning for SCI is considering options and strategies ranging from discharging patients with tents, constructing independent and integrated homes in a community, or creating large facilities that would house groups of people with disabilities. The latter option often is met with particular disdain and can elicit the suggestion that “institutionalizing” people in large centers would set back the global disability movement. Given that there is no one solution that is ideal or even appropriate in all settings, the empirical assessment of the each of these options (and others) would provide an evidence base to draw upon in future planning. Overall, the context and consequences of the Haiti earthquake can be used to generate useful and meaningful research, and the findings of that research in turn can be used not only to effectively plan future development in Haiti but to facilitate this process in other countries that will experience natural disasters in the years ahead. Evidence-based or evidence-informed research following natural disasters must include the investigation of clinical interventions and also must reach into system planning at the local, regional, and international levels. Ultimately, it may be our role as global citizens to first work in solidarity with Haitians, but we must then share important lessons learned so that we can improve emergency response. In doing so, we can search for some deeper meaning of the tragedy in Haiti, honor the immense loss of life, and give tribute to those who now struggle to regain their lives while living with disabilities. I propose that it is of paramount importance for physical therapists (and all health care professionals) to seek a moral and ethical balance between providing humanitarian services and engaging in research to more fully explore the health care outcomes of natural disasters. Unlike some of our past attempts as a global community, once we find this balance, we must then be prepared to deliver on it. Michel D. Landry, PT, PhD Assistant Professor, University of Toronto Adjunct Assistant Professor, University of North Carolina at Chapel Hill Adjunct Scientist, Toronto Rehabilitation Institute Toronto, Ontario, Canada Dr Landry has been working in global health for more than 15 years and has been involved in many post-conflict zones and countries affected by natural disasters. He is a past-president of the Canadian Physiotherapy Association and is leading the Toronto Rehabilitation Institute’s initiatives in Haiti. References 1 Pan American Health Organization (PAHO). Earthquake in Haiti: PAHO/WHO Situation Report on Health Activities Post Earthquake 18 May 2010. Available at: http://www.who.int/hac/crises/hti/en/. Accessed May 30, 2010. 2 United States Geological Society. Most destructive known earthquakes on record in the world. Available at: http://earthquake.usgs.gov/earthquakes/world/most_destructive.php. Accessed June 7, 2010. 3 O’Connell C, Shivji A, Calvot T. Handicap International Report: Preliminary Findings About Persons With Injuries. January 29, 2010. Available at: http://www.handicap-international.us/fileadmin/files/documents/ Preliminary_Injury_Report.pdf. Accessed June 1, 2010. [DOI: 10.2522/ptj.2010.90.7.974]

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Research Report Gait Biomechanics, Spatial and Temporal Characteristics, and the Energy Cost of Walking in Older Adults With Impaired Mobility David M. Wert, Jennifer Brach, Subashan Perera, Jessie M. VanSwearingen

Background. Abnormalities of gait and changes in posture during walking are more common in older adults than in young adults and may contribute to an increase in the energy expended for walking. Objective. The objective of this study was to examine the contributions of abnormalities of gait biomechanics (hip extension, trunk flexion, and foot-floor angle at heel-strike) and gait characteristics (step width, stance time, and cadence) to the energy cost of walking in older adults with impaired mobility.

Design. A cross-sectional design was used. Methods. Gait speed, step width, stance time, and cadence were derived during walking on an instrumented walkway. Trunk flexion, hip extension, and foot-floor angle at heel contact were assessed during overground walking. The energy cost of walking was determined from oxygen consumption data collected during treadmill walking. All measurements were collected at the participants’ usual, self-selected walking speed.

Results. Fifty community-dwelling older adults with slow and variable gait participated. Hip extension, trunk flexion, and step width were factors related to the energy cost of walking. Hip extension, step width, and cadence were the only gait measures beyond age and gait speed that provided additional contributions to the variance of the energy cost, with mean R2 changes of .22, .12, and .07, respectively.

Limitations. Other factors not investigated in this study (interactions among

D.M. Wert, PT, MPT, is Research Physical Therapist/Research Assistant, Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA). Address all correspondence to Mr Wert at: [email protected]. J. Brach, PT, PhD, is Assistant Professor, Department of Physical Therapy, University of Pittsburgh. S. Perera, PhD, is Associate Professor, Division of Geriatric Medicine, University of Pittsburgh. J.M. VanSwearingen, PT, PhD, FAPTA, is Associate Professor, Department of Physical Therapy, University of Pittsburgh. [Wert DM, Brach J, Perera S, VanSwearingen JM. Gait biomechanics, spatial and temporal characteristics, and the energy cost of walking in older adults with impaired mobility. Phys Ther. 2010;90:977–985.] © 2010 American Physical Therapy Association

variables, psychosocial factors, muscle strength [force-generating capacity], range of motion, body composition, and resting metabolic rate) may further explain the greater energy cost of walking in older adults with slow and variable gait.

Conclusions. Closer inspection of hip extension, step width, and cadence during physical therapy gait assessments may assist physical therapists in recognizing factors that contribute to the greater energy cost of walking in older adults.

Post a Rapid Response to this article at: ptjournal.apta.org July 2010

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Energy Cost of Walking in Older Adults

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bnormalities of gait and changes in posture during walking are more common in older adults than in young adults1– 4 and may contribute to an increase in the energy expended for walking.5,6 The energy cost of walking at a comfortable speed has been shown to differ between older and young adults, with older adults having a greater energy cost of walking than young adults.7 Oxygen consump˙ O2) and, ultimately, energy tion (V ˙ O2 standardized by gait cost (mean V speed) are important because they represent an individual’s physiological ability to provide energy to support life and various levels of physical activity. Because routine physical activity accounts for 15% to 30% of an adult’s total daily energy expenditure and because walking is the most prevalent physical activity for most people,8 assessing the energy cost of walking in older adults can play a vital role in providing interventions for maintaining optimum independent functioning in older adults. A greater energy cost of walking has been related to a poorer self-report of function in older adults with mobility disability.9 The reason for the greater energy cost of walking in older adults remains unclear, although previous research indicated that certain biomechanical factors and gait characteristics may explain the increased cost. Waters et al10 demonstrated that the energy cost of walking is greater for people with hip or ankle

Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on May 20, 2010, at ptjournal.apta.org.

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fusions and knee motion restrictions than for people without such restrictions. Researchers studying age-related differences in gait have shown that older adults have reduced gait speed,2– 4,7 less hip and knee extension, reduced ankle dorsiflexion angle at heel-strike,2– 4,11,12 decreased step and stride length, and altered step width.1– 4,13,14 Additionally, increases in double-support time, stance time, and quadriceps energy absorption4,12,13,15 and a reduction in power during toe-off 4 also have been reported in older adults. Although the influences of gait speed16,17 and step width5 on the energy cost of walking were previously explored, the association between the energy cost of walking and other frequently assessed gait biomechanical factors (trunk flexion and reduced hip and ankle motion)18 –21 and gait characteristics (cadence, stance time, and step length)18,20,22,23 has not been as well documented. The purpose of this study was to examine the contributions of abnormalities of gait biomechanics (hip extension, trunk flexion, and foot-floor angle at heel-strike) and gait characteristics (step width, stance time, and cadence) that are commonly assessed in physical therapy research and clinical gait evaluations14,18 –27 to the energy cost of walking in older adults with impaired mobility. Physical therapists often assess the gait of older adults to guide clinical decision making for interventions and the prevention of future disabilities in mobility and activities of daily living. By identifying the primary factor or combination of factors that contributes to a greater energy cost of walking, physical therapists can target interventions to the underlying gait characteristics and biomechanical factors with the goal of improving walking efficiency in older adults.

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Method Study Design and Participants Gait biomechanics, gait characteristics, and the energy cost of walking in the current cross-sectional study were evaluated as part of the baseline assessment for a pilot randomized controlled trial of 2 interventions for improving walking in older adults with mobility disability.26 Gait measurements were collected during 2 baseline clinic visits that were 1 week apart. Older adults aged 65 years or older who were community-dwelling, were able to ambulate without an assistive device other than a straight cane and without the assistance of another person, and had slow (walking speed of 0.6 –1.0 m/s) and variable (step length coefficient variability of ⬎4.5% or step width variability of ⬍7% or ⬎30%) gait participated in this study.26 People who had dyspnea at rest, diagnosed dementia or cognitive impairment (defined as a Mini-Mental State Examination score of ⬍24), hemiparesis with lowerextremity strength (force-generating capacity) of less than 4 –/5 (manual muscle test grade), a fixed or fused lower-extremity joint or amputation, or a progressive motor disorder such as multiple sclerosis or Parkinson disease were excluded. Fifty participants completed the baseline assessment. All participants signed a consent form approved by the University of Pittsburgh Institutional Review Board. Procedure Gait speed, mean step width, mean stance time, and cadence were assessed during walking on a GaitMat II* instrumented walkway. Trunk flexion, hip extension, and foot-floor angle at heel contact were assessed during overground walking shortly * EQ Inc, PO Box 16, Chalfont, PA 189140016.

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Energy Cost of Walking in Older Adults after the GaitMat II measurements were obtained. The energy cost of ˙ O2 walking was determined from V data collected during treadmill walking. All walking conditions were completed at the participants’ usual, self-selected walking speed. Participants practiced on the treadmill during the initial clinic visit and were given ample time to achieve their usual walking pace before data collection on the second visit. Measures Gait characteristics: gait speed, mean step width, mean stance time, and cadence. The GaitMat II system is an instrumented walkway that is approximately 4 m long; the initial and final 2 m are inactive to allow for acceleration and deceleration. The automated gait analysis system is based on the opening and closing of pressure-sensitive switches that are represented on the computer screen as footprints when the participant walks on the walkway. After 2 practice passes on the GaitMat II, participants completed 2 additional passes at their usual, selfselected walking speed for data collection. The mean for each gait characteristic was determined from the average values recorded during the 2 passes and used as the gait characteristic measure.28 The GaitMat II has been shown to be a reliable and valid measurement tool for older adults24,28 –30 and has been widely used for gait analysis.14,22,24,28–32 Gait biomechanics: trunk flexion, foot-floor angle, and hip extension. We were specifically interested in trunk flexion, foot-floor angle at heel-strike, and hip extension during gait because abnormalities are commonly observed in these aspects of gait in older adults. Trunk flexion, foot-floor angle at heelstrike, and hip extension were determined by an assessor who was unaware of the participants’ other gait July 2010

measurements; the assessor viewed a videotape of the participants walking at their usual, self-selected speed over a level surface, with front, side, and back views. The assessments were made shortly after the GaitMat II data were recorded by use of the modified Gait Abnormality Rating Scale27 (GARS-M); criterion-based item scores (0 –3) were assigned for items 2, 4, and 5. Higher scores represent greater biomechanical abnormalities (for intrarater item reliability, generalized kappa⫽.676 and intraclass correlation coefficient⫽ .984).27 Trunk flexion (GARS-M item 2) was assigned a value based on the severity of trunk flexion: a value of 0 was assigned when the trunk was positioned upright over the base of support at push-off, a value of 1 was assigned when the trunk was flexed slightly in front of the base of support at push-off, a value of 2 was assigned when the trunk was flexed

over the anterior aspect of the foot at push-off, and a value of 3 was assigned when the trunk was held over the rear aspect of the stance foot. The foot-floor angle at heel-strike (GARS-M item 4) was assigned a value of 0 when there was an obvious angle of the foot during impact of the heel on the ground, a value of 1 when the foot angle was barely visible during contact of the heel (before forefoot contact), a value of 2 when the entire foot landed flat on the ground, and a value of 3 when the anterior aspect of the foot struck the ground before the heel. Hip extension (GARS-M item 5) was assigned a value of 0 when there was an obvious backward angle of the preswing thigh during double support, a value of 1 when the preswing thigh angle was beyond the vertical projection from the ground and was just barely visible, a value of

The Bottom Line What do we already know about this topic? A greater than usual energy cost of walking has been demonstrated for older adults, for people with restricted lower-extremity joint motion, and for persons with altered gait characteristics. Less is known about the relative contribution of specific age-related gait abnormalities to the energy cost of walking in older adults with mobility disability.

What new information does this study offer? Gait abnormalities of hip extension, step width, and cadence were substantial independent contributors to the energy cost of walking in older adults with mobility disability.

If you’re a patient, what might these findings mean to you? A closer inspection of hip extension, step width, and cadence during physical therapy gait assessments may assist physical therapists in recognizing inefficiencies of gait. A better understanding of the underlying mechanisms of inefficient gait could be used to develop targeted interventions to improve gait efficiency.

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Energy Cost of Walking in Older Adults Table 1.

expired gases.33,34 A metabolic measurement system (Medgraphics ˙ O2 VO2000†) was used to measure V at the physiological steady state for up to 6 minutes while the participants walked on a treadmill at their usual, self-selected walking speed. A ˙ O2 was determeasure of mean V ˙ O2 recorded for mined by averaging V 3 minutes during the physiological steady state8 (at ⬃2–3 minutes after the initiation of walking at the usual, self-selected speed). The energy cost of walking (mL/kg䡠m) was calculated by dividing the body mass–corrected ˙ O2 (mL/kg䡠min) by gait speed mean V (m/min).

Characteristics of Study Participants (N⫽50) Measurea

Value

Age, y

76.7 (75.3–78.3)

Sex, % female

65

Energy cost, mL/kg䡠m

0.30 (0.27–0.33)

Gait speed, m/s

0.88 (0.84–0.93)

Comorbiditiesb

4.3 (3.7–5.0)

Step width, m

0.09 (0.07–0.12)

Stance time, s

0.74 (0.72–0.77)

Cadence, steps/min

100 (95–104)

GARS-M hip itemsc 0

17 (34)

1

16 (32)

ⱖ2

17 (34)

All participants were given time for treadmill familiarization during the first clinic visit and were encouraged to find their usual walking speed on the treadmill. To allow for ample familiarization, the energy cost data were collected during a second clinic visit. Participants were asked whether they had experienced any events or circumstances that might influence their ability to walk as they did at the first visit; no participant reported an alteration in ability to walk at the usual, self-selected pace.

GARS-M trunk itemsc 0

4 (8)

1

38 (76)

ⱖ2

8 (16)

GARS-M ankle itemsc 0

24 (48)

1

20 (40)

ⱖ2

6 (12)

a

Reported as mean (95% confidence interval) unless otherwise indicated. b Up to 18 comorbidities. c Reported as frequency (%) (for the 50 study participants). GARS-M⫽modified Gait Abnormality Rating Scale.

2 when the preswing thigh angle was in line with vertical, and a value of 3 when the preswing thigh angle was forward of vertical. Few participants had scores of 3 (severe limitation); therefore, we consolidated those with scores of 2 (moderate limitation) and those with scores of 3 (severe limitation) during the initial scoring into a group with scores of greater than or equal to 2. The GARS-M has been shown to be a reliable and valid assessment tool for analyzing gait,22,27 and the psychometric properties of individual item scores have been demonstrated.27 Energy cost of walking. Energy cost was determined by use of indirect calorimetry and analysis of 980

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Comorbidities The presence of comorbidities was ascertained with the Comorbidity Index,35 which includes 18 diseases. The total number of positive responses (0 –18) indicating the presence of a particular disease was recorded. Data Analysis We used SAS version 9.2‡ for all statistical analyses. We used appropriate descriptive statistics (mean, standard deviation, frequency, and percentage) to summarize participant characteristics. We computed † Medical Graphics Corp, 350 Oak Grove Pkwy, St Paul, MN 55127. ‡ SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.

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the Pearson product moment and Spearman rank correlation coefficients, as appropriate, to quantify the association between the energy cost of walking and each of the gait measures. To assess the influence of gait biomechanics on the energy cost of walking, we fit a series of multiple regression models with the energy cost of walking as the dependent variable and predictor variables chosen to be consistent with the theoretical postulation of contributors to the energy cost of walking on the basis of the literature and our clinical experience. For the first model (model 1), we included the predictor variables age and gait speed as well-known or obvious contributors to the energy cost of walking3–5,11,14,15,36 and each measure of gait characteristics (step width, stance time, and cadence) and gait biomechanics (GARS-M hip, trunk, and ankle items). For the second model (model 2), with recognition of the importance of the hip,11,37,38 we added the GARS-M hip item and each of the remaining measures of gait characteristics and gait biomechanics as additional predictor variables. The total number of predictor variables was limited to only 4 to avoid model overfitting because there were only 50 study participants. We used R2 for each model and the increase in R2 between models to quantify the contributions of measures of gait biomechanics beyond age and gait speed to the energy cost of walking. We used the nestedmodel F test to assess statistical significance. Role of the Funding Source Funding was provided by the Pittsburgh Claude D. Pepper Older Americans Independence Center (grant P30 AG024827) and the National Institute on Aging and American Federation of Aging Research Paul July 2010

Energy Cost of Walking in Older Adults Table 2. Correlations Among Gait Characteristics and Biomechanical Factors Correlation Coefficient (P) for: Variable Agea Energy cost

Age

Energy Cost

Gait Speed

Step Width

1.00

⫺.011 (.94)

⫺.355 (.01)

.230 (.11)

1.00

⫺.286 (.04)

a

Gait speeda

1.00

Step widtha

.373 (⬍.01) ⫺.242 (.09) 1.00

Stance Time

Cadence

Hip Extension

Trunk Flexion

Foot-Floor Angle

.103 (.48)

⫺.027 (.85)

.199 (.17)

.236 (.10)

.130 (.37)

⫺.069 (.63)

.166 (.25)

.523 (⬍.01)

⫺.484 (.01)

.279 (.05)

⫺.371 (⬍.01)

.352 (.01)

⫺.215 (.13)

Stance timea

1.00

Cadencea

.232 (.10) ⫺.546 (.01)

.497 (⬍.01)

.402 (.02)

.043 (.76)

⫺.918 (.01)

.057 (.69)

.140 (.33)

.156 (.28)

1.00

.113 (.44)

⫺.068 (.64)

⫺.011 (.94)

Hip extensionb Trunk flexion

.395 (⬍.01) ⫺.465 (.01)

1.00

.505 (⬍.01)

b

1.00

.463 (⬍.01) .259 (.07)

Foot-floor angleb a b

1.00

Reported as Pearson correlation coefficient. Reported as Spearman correlation coefficient.

Table 3. Additional Explanatory Power of Variables Beyond Age and Gait Speed and Beyond Age, Gait Speed, and Hip Extension Model 1 (Age ⴙ Gait Speed ⴙ Added Variable)

Model 2 (Age ⴙ Gait Speed ⴙ Hip Extension ⴙ Added Variable)

R2

Change in R2 (P) With Added Variable

R2

Change in R2 (P) With Added Variable

Step width

.21

.12 (.01)

.34

.03 (.17)

Stance time

.16

.06 (.06)

.34

.03 (.16)

Cadence

.17

.07 (.05)

.33

.02 (.24)

Hip extension

.31

.22 (.002)

Trunk flexion

.17

.08 (.12)

.33

.02 (.53)

Foot-floor angle

.17

.08 (.14)

.38

.06 (.12)

Added Variable

Beeson Career Development Award (K23 AG026766) for personnel, participant support for travel and time, data collection, and analyses.

Results The mean age of the participants was 76.7 years (SD⫽5.4 years), and 65% were women. This sample of older adults with impaired mobility walked slowly (mean gait speed⫽0.88 m/s); had mild to moderate severities of trunk flexion abnormalities, reduced foot-angle contact, and hip extension abnormalities; and had a greater energy cost of walking (0.30 mL/kg䡠m) at their usual, self-selected walking pace than older adults without mobility problems (0.16 mL/kg䡠m)38 (Tab. 1). July 2010

Three of the 6 gait characteristics and biomechanical factors assessed— hip extension, trunk flexion, and step width—were related to the energy cost of walking. The greater the severity of abnormalities of hip extension and trunk flexion and the wider the step width, the greater the energy cost of walking (Tab. 2). Multiple linear regression analyses were performed for each measure, while controlling for age and gait speed, to assess the contribution of each measure to the energy cost of walking. Hip extension, step width, and cadence were the only gait measures beyond age and gait speed that provided additional contributions to the variance of the energy cost

of walking (Tab. 3, model 1), with mean R2 changes of .22 (P⬍.002), .12 (P⫽.01), and .07 (P⫽.05), respectively. Expanding the model to include 4 gait variables, while controlling for age, gait speed, and hip extension, failed to provide any additional factor explaining the variance in the energy cost of walking (Tab. 3, model 2). The increase in the energy cost of walking with successive increases in the severity of hip extension abnormalities is shown in the Figure. The greater the severity of reduced hip extension (none, mild, and moderate), the greater the energy cost of walking, with values of 0.23, 0.31, and 0.36 mL/kg䡠m, respectively

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Energy Cost of Walking in Older Adults

Figure. Reduced hip extension and energy cost of walking. Energy cost was adjusted for age and gait speed. For GARS hip item scores, 0 represented no limitation in hip extension and ⱖ2 represented moderate to severe limitations in hip extension. For hip item scores of 1 versus 0, ␤⫽.08; for hip item scores of ⱖ2 versus 0, ␤⫽.13. A score of 1 was significantly different from a score of 0 at P⬍.05; a score of ⱖ2 was significantly different from a score of 0 at P⬍.01.

(F⫽4.98; df⫽4,48; P value for trend, .002).

Discussion In our sample of older adults with slow and variable gait, the lack of hip extension during walking explained a substantial proportion of the variance in the energy cost of walking. Step width and cadence also contributed to the variance in the energy cost of walking, but to a lesser extent. Our findings regarding the contributions of gait characteristics and gait biomechanics to the energy cost of walking are consistent with those of previous investigations. The older adults with greater step width values in the present study had a greater energy cost of walking. In earlier work, Donelan et al5 reported that experimentally altered step width was a significant contributor to the energy cost of walking in adults (wider widths ⬎ narrower widths). They suggested that the increased energy cost associated with altered step widths was the result of the increased work required to redirect 982

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the body’s velocity during step-tostep transitions and, to a lesser extent, the added work of moving the swing leg laterally to avoid the stance leg (narrow step width).5 Likewise, we surmise that the additional work required with increased walking cadences is likely due to increased muscle demands for more frequent limb progression and ground contact. Changes in muscle activity related to altered posture and associated compensation were suggested to be major contributors to the increased energy cost in a study performed by Saha et al,6 who analyzed forceplate, kinematic, and metabolic energy data in a group of young adults. They reported that with increasing trunk flexion, there was a significant in˙ O2, most likely due to the crease in V increase in muscle activity needed to support the trunk and head against gravity and maintain upright balance. In our sample of older adults with slow and variable gait, limitations in hip extension during walking ac-

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counted for 22% of the variance in the energy cost of walking. How do limitations in hip extension influence the energy cost of walking? In humans, the important peripheral sensory information for regulating stepping is the stimulus for signaling the transition from stance to swing. The sensory stimulus arises from sensory nerves in the anterior thigh and is activated by hip extension during gait as the foot moves behind the body.36 Thus, hip extension is an important signal for firing of the central pattern generator neurons that are responsible for consistent stepping during gait36,39,40; the reduced hip extension observed with aging may diminish the signal needed for the central pattern generator to generate regular stepping. Without a clear and consistent signal for stepping, the timing of stepping in the gait cycle can become disrupted, leading to an altered and potentially more costly pattern of gait. Such disruptions to the normal gait pattern can alter muscle firing patterns and increase variability during the phases of gait, in turn requiring ˙ O2 to meet the enan increase in V ergy demand of additional or more frequently used muscles. Greater energy demands during walking can have a significant impact on the energy reserves of older adults. On the basis of previous exercise testing and physiological research,8,41 older adults with a mean age of 77 years and with slow and variable gait could be estimated to ˙ O2 of approxihave a maximal V mately 22 mL/kg䡠min.42– 44 We can ˙ O2 associated with the estimate the V severity of hip extension by multiplying the energy cost of walking at each level of hip abnormality by the mean gait speed of the sample. Oxygen consumption during walking at 0.89 m/s with no hip extension abnormality would be 12.3 mL/kg䡠min, ˙ O2 or 59% of the estimated maximal V for an older adult with slow and variJuly 2010

Energy Cost of Walking in Older Adults able gait. Oxygen consumption associated with mild and moderate severities of hip extension abnormalities would be 16.6 and 19.2 mL/kg䡠min, respectively, and would account for ˙ O2 for 75% and 87% of the maximal V an older adult. Thus, older adults with more severe hip extension abnormalities are working closer to ˙ O2 (75%– 87%) just their maximal V during typical walking, leaving a small energy reserve (13%–25%). Because walking has been shown to be the most frequently performed physical activity throughout the course of a day,8 working at levels close to the ˙ O2 may begin to limit maximum for V how much reserve older adults have for performing other daily tasks and physical activities. Older adults with slow and variable gait and moderately severe hip extension abnormalities experience a greater energy cost during walking, reducing their reserve for completing other daily tasks. Although the difference in energy costs between mild and moderate severities of hip extension abnormalities (scores of 1 and 2) was not statistically significant, the difference of 0.044 mL/kg䡠m approaches a moderate meaningful difference of 0.05 mL/kg䡠m (SD ⫻ moderate effect size⫽difference) and would account ˙ O2, to nearly for a 9% increase in V ˙ O2. 84% of maximal V A closer examination of the energy cost of walking in our sample of older adults without hip extension limitations revealed that the energy cost of walking remained greater than that reported for older adults without mobility disabilities (0.23 mL/kg䡠m versus 0.16 – 0.18 mL/ kg䡠m). Our sample of older adults was selected on the basis of slow and variable gait, which may account for the greater cost of walking in these adults than in older adults without these characteristics. Additionally, the greater energy cost may be explained by the fact that other gait abnormalities were observed in July 2010

older adults with slow and variable gait. Of the 16 older adults without hip extension limitations (GARS-M hip item score⫽0), 13 appeared to have altered step widths (wide or narrow), 10 had a higher-thannormal walking cadence, 14 had some trunk flexion abnormality, and 3 had a mild degree of decreased foot-floor contact angle at heelstrike. Additionally, the mean stance time variability (the SD of stance time) of our sample of older adults with slow and variable gait was 0.076 second, greater than the value of 0.037 second that has been associated with mobility disability.45 Although not measured in the present study, stance time variability also may influence the energy cost of walking. Limitations The results of the present study must be interpreted with some caution and applied to similar samples of older adults with slow and variable gait. Our study was cross-sectional in nature; therefore, we cannot infer a cause-effect relationship between the gait variables and energy cost. Mea˙ O2 and gait biomechansurements of V ics were not collected concurrently; gait biomechanics and characteristics were measured within minutes of ˙ O2 data were each other, whereas V collected during treadmill walking at a second clinic visit, 1 week later. We believe that nonconcurrent measurement collection had little impact on our findings because measures of mean gait speed and gait characteristics have been shown to have good test-retest reliability28 and because all measurements were obtained at a usual, self-selected walking pace under typical circumstances. Views regarding the energy cost of walking at similar speeds on a treadmill versus overground continue to differ within the literature. In young adults who were healthy, Stoquart et al46 compared the cost of walking at

various speeds on a treadmill with the energy cost assessed overground at the same speeds by DeJaeger et al47 and reported that the actual cost values were lower during the treadmill walking versus overground walking, whereas the mean energy costs of walking at like speeds were similar. A different outcome was reported by Parvataneni et al,48 who recently investigated the metabolic cost of treadmill versus overground walking in older adults who were healthy and reported a 23% higher metabolic requirement during treadmill walking. Although this is a substantial difference in energy cost between the 2 walking conditions, data are lacking regarding the potential for greater agonist-antagonist cocontraction during treadmill walking without handrails, which may account for the increased cost of walking. As seen above, the few studies that have compared the energy cost of treadmill and overground walking have been performed primarily on young or older adults who were healthy. In our study of slow and variable older adults, we believe that there is the potential that the treadmill may have positively influenced the biomechanics (ie, improved hip extension) of the participants, thereby reducing the full impact of biomechanics on the energy cost of walking, resulting in a lower cost of walking than would have been observed overground. The treadmill has been shown to promote improved gait mechanics in individuals with abnormal gait25 and to reduce some forms of gait variability,49 which we think may allow for a more efficient form of gait and potentially lower the energy cost of walking in individuals with mobility disability compared with overground walking (and young adults who are healthy). The differences observed in the current literature support the need for continued research regarding the best and most accurate method of as-

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Energy Cost of Walking in Older Adults sessing the cost of walking in older adults. We understand that factors other than those investigated in the present study (eg, interactions between gait variables, psychosocial factors, muscle strength, range of motion, body composition, resting metabolic rate) may further explain the greater energy cost of walking in older adults with slow and variable gait. We encourage future investigations with larger samples of older adults to allow more factors to be placed in models attempting to explain the variance of the energy cost of walking. We also recognize that the use of an observational assessment of gait biomechanics has a limited ability to discriminate small differences in biomechanics compared with motion analysis; however, the observational assessment has been shown to be a reliable and valid measure22,27 of gait abnormalities and is a feasible and affordable method of assessment for most clinical settings. Interventions aimed at addressing limitations in hip extension during gait continue to evolve. Some earlier research revealed slight improvements in peak hip extension during gait in older adults after an intervention aimed at improving static hip extension range of motion.37 However, more recent work suggested that the reduction in peak hip extension seen during walking in older adults is related to gait (dynamic) rather than postural decline.50 On the basis of the idea that reduced hip extension during gait may be related to gait rather than posture, VanSwearingen et al26 implemented a movement control intervention (timing and coordination) that secondarily engaged greater hip extension. They reported an improvement in the efficiency (reduction in the energy cost) of walking in a group of older adults with mobility problems. Longitudinal studies investigating 984

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the natural history of gait abnormalities and biomechanical changes during walking would provide a better understanding of the patterns and contributions of gait limitations to the energy cost of walking and further enhance the ability to provide early and effective interventions for restoring efficient walking in older adults.

Conclusions Mechanisms related to the initiation and stepping patterns of gait, such as hip extension, step width, and cadence, were found to be related to the energy cost of walking in older adults with slow and variable gait. A closer inspection of hip extension, step width, and cadence during physical therapy gait assessments may assist physical therapists in recognizing factors that contribute to the greater energy cost of walking in older adults and suggest specific interventions aimed at returning older adults to a more efficient pattern of walking. All authors provided concept/idea/research design, writing, and data analysis. Mr Wert, Dr Brach, and Dr VanSwearingen provided data collection. Dr VanSwearingen provided project management. Dr Brach and Dr VanSwearingen provided fund procurement and facilities/equipment. This study was approved by the University of Pittsburgh Institutional Review Board. Funding was provided by the Pittsburgh Claude D. Pepper Older Americans Independence Center (grant P30 AG024827) and a National Institute on Aging and American Federation of Aging Research Paul Beeson Career Development Award (K23 AG026766) for personnel, participant support (travel and time), data collection, and analyses. This article was submitted September 27, 2009, and was accepted April 1, 2010. DOI: 10.2522/ptj.20090316

References 1 Blanke DJ, Hageman PA. Comparison of gait of young men and elderly men. Phys Ther. 1989;69:144 –148.

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2 Hageman PA, Blanke DJ. Comparison of gait of young women and elderly women. Phys Ther. 1986;66:1382–1387. 3 Ostrosky KM, VanSwearingen JM, Burdett RG, Gee Z. A comparison of gait characteristics in young and old subjects. Phys Ther. 1994;74:637–644; discussion 644–646. 4 Winter DA, Patla AE, Frank JS, Walt SE. Biomechanical walking pattern changes in the fit and healthy elderly. Phys Ther. 1990;70:340 –347. 5 Donelan JM, Kram R, Kuo AD. Mechanical and metabolic determinants of the preferred step width in human walking. Proc R Soc Lond Ser B Biol Sci. 2001;268: 1985–1992. 6 Saha D, Gard S, Fatone S, Ondra S. The effect of trunk-flexed postures on balance and metabolic energy expenditure during standing. Spine (Phila Pa 1976). 2007;32: 1605–1611. 7 Waters RL, Lunsford BR, Perry J, Byrd R. Energy-speed relationship of walking: standard tables. J Orthop Res. 1988;6: 215–222. 8 McArdle WD, Katch FI, Katch VL. Exercise Physiology. 2nd ed. Philadelphia, PA: Lea & Febiger; 1986. 9 Wert DM, BJ, VanSwearingen J. Energy cost of walking contributes to physical function in older adults. In: American Geriatrics Society Annual Conference. 2009 Annual Scientific Meeting Abstract Book. Vol 57 (4). Chicago, IL: Wiley-Blackwell; 2009. 10 Waters RL, Barnes G, Husserl T, et al. Comparable energy expenditure after arthrodesis of the hip and ankle. J Bone Joint Surg Am. 1988;70:1032–1037. 11 Kerrigan DC, Lee LW, Collins JJ, et al. Reduced hip extension during walking: healthy elderly and fallers versus young adults. Arch Phys Med Rehabil. 2001;82: 26 –30. 12 McGibbon CA, Krebs DE. Discriminating age and disability effects in locomotion: neuromuscular adaptations in musculoskeletal pathology. J Appl Physiol. 2004; 96:149 –160. 13 McGibbon CA. Toward a better understanding of gait changes with age and disablement: neuromuscular adaptation. Exerc Sport Sci Rev. 2003;31:102–108. 14 Brach JS, Studenski S, Perera S, et al. Stance time and step width variability have unique contributing impairments in older persons. Gait Posture. 2008;27:431– 439. 15 Watelain E, Barbier F, Allard P, et al. Gait pattern classification of healthy elderly men based on biomechanical data. Arch Phys Med Rehabil. 2000;81:579 –586. 16 Martin PE, Rothstein DE, Larish DD. Effects of age and physical activity status on the speed-aerobic demand relationship of walking. J Appl Physiol. 1992;73:200 –206. 17 Pearce ME, Cunningham DA, Donner AP, Rechnitzer PA, et al. Energy cost of treadmill and floor walking at self-selected paces. Eur J Appl Physiol Occup Physiol. 1983;52:115–119.

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Energy Cost of Walking in Older Adults 18 Barak Y, Wagenaar RC, Holt KG. Gait characteristics of elderly people with a history of falls: a dynamic approach. Phys Ther. 2006;86:1501–1510. 19 Lennon S. Gait re-education based on the Bobath concept in two patients with hemiplegia following stroke. Phys Ther. 2001; 81:924 –935. 20 Marchetti GF, Whitney SL, Blatt PJ, et al. Temporal and spatial characteristics of gait during performance of the Dynamic Gait Index in people with and people without balance or vestibular disorders. Phys Ther. 2008;88:640 – 651. 21 McGinley JL, Goldie PA, Greenwood KM, Olney SJ. Accuracy and reliability of observational gait analysis data: judgments of push-off in gait after stroke. Phys Ther. 2003;83:146 –160. 22 Huang WN, VanSwearingen JM, Brach JS. Gait variability in older adults: observational rating validated by comparison with a computerized walkway gold standard. Phys Ther. 2008;88:1146 –1153. 23 Yogev-Seligmann G, Hausdorff JM, Giladi N. The role of executive function and attention in gait. Mov Disord. 2008;23:329 – 342; quiz 472. 24 Brach JS, Berthold R, Craik RL, et al. Gait variability in community-dwelling older adults. J Am Geriatr Soc. 2001;49:1646 – 1650. 25 Herman T, Giladi N, Gruendlinger L, Hausdorff JM. Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson’s disease: a pilot study. Arch Phys Med Rehabil. 2007;88: 1154 –1158. 26 VanSwearingen JM, Perera S, Brach JS, et al. A randomized trial of two forms of therapeutic activity to improve walking: effect on the energy cost of walking. J Gerontol A Biol Sci Med Sci. 2009;64: 1190 –1198. 27 VanSwearingen JM, Paschal KA, Bonino P, Yang JF. The modified Gait Abnormality Rating Scale for recognizing the risk of recurrent falls in community-dwelling elderly adults. Phys Ther. 1996;76:994 –1002. 28 Brach JS, Perera S, Studenski S, Newman AB. The reliability and validity of measures of gait variability in community-dwelling older adults. Arch Phys Med Rehabil. 2008;89:2293–2296.

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29 Barker S, Craik RL, Freedman W, et al. Accuracy, reliability, and validity of a spatiotemporal gait analysis system. Med Eng Phys. 2006;28:460 – 467. 30 Pomeroy VM, Chambers SH, Giakis G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18:222–227. 31 Brach JS, Studenski SA, Perera S, et al. Gait variability and the risk of incident mobility disability in community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2007; 62:983–988. 32 Sicard-Rosenbaum L, Light KE, Behrman AL. Gait, lower extremity strength, and self-assessed mobility after hip arthroplasty. J Gerontol A Biol Sci Med Sci. 2002;57: M47–M51. 33 Macko RF, Smith GV, Dobrovolny CL, et al. Treadmill training improves fitness reserve in chronic stroke patients. Arch Phys Med Rehabil. 2001;82:879 – 884. 34 Waters RL, Lunsford BR. Energy cost of paraplegic locomotion. J Bone Joint Surg Am. 1985;67:1245–1250. 35 Rigler SK, Studenski SA, Wallace D, et al. Co-morbidity adjustment for functional outcomes in community-dwelling older adults. Clin Rehabil. 2002;16:420 – 428. 36 Capaday C. The special nature of human walking and its neural control. Trends Neurosci. 2002;25:370 –376. 37 Kerrigan DC, Xenopoulos-Oddsson A, Sullivan MJ, et al. Effect of a hip flexorstretching program on gait in the elderly. Arch Phys Med Rehabil. 2003;84:1– 6. 38 Waters R. Energetics. In: Perry J, ed. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992:455. 39 Pang MY, Yang JF. Interlimb co-ordination in human infant stepping. J Physiol. 2001; 533:617– 625. 40 Rossignol S. Neural control of stereotypic limb movements. In: Rowell LG, Shepherd JT, eds. Exercise: Regulation and Integration of Multiple Systems. New York, NY: Oxford University Press; 1996:173–216. 41 Wasserman K, Hansen JE, Sue DY, et al. Principles of Exercise Testing and Interpretation. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

˙ O2max norms. Topend Sports Network 42 V Web site. Available at: www.topendsports. com/testing/vo2norms.htm. Accessed April 19, 2010. ˙ O2max norms for women. About.com: 43 V Sports Medicine Web site. Available at: http://sportsmedicine.about.com/od/fitness evalandassessment/a/VO2_Norms.htm. Accessed April 19, 2010. 44 The Bruce treadmill test protocol. About. com: Sports Medicine Web site. Available at: http://sportsmedicine.about.com/od/ fitnessevalandassessment/a/Bruce_Protocol. htm. Accessed April 19, 2010. 45 Brach JS, VanSwearingen JM, Studenski SA, Perera S, Newman AB. Values of stance time variability related to mobility disability. J Geriatr Phys Ther. 2006;29:118. 46 Stoquart G, Detrembleur C, Lejeune T. Effect of speed on kinematic, kinetic, electromyographic, and energetic reference values during treadmill walking. Clin Neurophysiol. 2008;38:105–116. 47 DeJaeger D, Willems PA, Heglund NC. The energy cost of walking children. Pfugers Arch. 2001;441:538 –543. 48 Parvataneni K, Ploeg L, Olney S, Brouwer B. Kinematic, kinetic, and metabolic parameters of treadmill versus overground walking in healthy older adults. Clin Biomech. 2009;24:95–100. 49 Warabi T, Kato M, Kiriyama K, et al. Treadmill walking and overground walking of human subjects compared by recording sole-floor reaction force. Neurosci Res. 2005;53:343–348. 50 Lee LW, Zavarei K, Evans J, et al. Reduced hip extension in the elderly: dynamic or postural? Arch Phys Med Rehabil. 2005; 86:1851–1854.

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Research Report Trunk and Hip Muscle Activation Patterns Are Different During Walking in Young Children With and Without Cerebral Palsy Laura A. Prosser, Samuel C.K. Lee, Ann F. VanSant, Mary F. Barbe, Richard T. Lauer L.A. Prosser, PT, PhD, is Postdoctoral Fellow, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bldg 10-CRC, 1-1469, 10 Center Dr, Bethesda MD 20892 (USA). Address all correspondence to Dr Prosser at: [email protected]. S.C.K. Lee, PT, PhD, is Assistant Professor, Physical Therapy Department, University of Delaware, Newark, Delaware, and Research Associate, Shriners Hospitals for Children, Philadelphia, Pennsylvania. A.F. VanSant, PT, PhD, FAPTA, is Professor, Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania. M.F. Barbe, PhD, is Professor, Departments of Physical Therapy and Anatomy and Cell Biology, Temple University. R.T. Lauer, PhD, is Assistant Professor, Departments of Physical Therapy and Electrical and Computer Engineering, Temple University. [Prosser LA, Lee SCK, VanSant AF, et al. Trunk and hip muscle activation patterns are different during walking in young children with and without cerebral palsy. Phys Ther. 2010;90:986 –997.]

Background. Poor control of postural muscles is a primary impairment in people with cerebral palsy (CP). Objective. The purpose of this study was to investigate differences in the timing characteristics of trunk and hip muscle activity during walking in young children with CP compared with children with typical development (TD).

Methods. Thirty-one children (16 with TD, 15 with CP) with an average of 28.5 months of walking experience participated in this observational study. Electromyographic data were collected from 16 trunk and hip muscles as participants walked at a self-selected pace. A custom-written computer program determined onset and offset of activity. Activation and coactivation data were analyzed for group differences.

Results. The children with CP had greater total activation and coactivation for all muscles except the external oblique muscle and differences in the timing of activation for all muscles compared with the TD group. The implications of the observed muscle activation patterns are discussed in reference to existing postural control literature.

Limitations. The potential influence of recording activity from adjacent deep trunk muscles is discussed, as well as the influence of the use of an assistive device by some children with CP. Conclusions. Young children with CP demonstrate excessive, nonreciprocal trunk and hip muscle activation during walking compared with children with TD. Future studies should investigate the efficacy of treatments to reduce excessive muscle activity and improve coordination of postural muscles in CP.

© 2010 American Physical Therapy Association

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muscles in individuals with CP may guide the design of postural control interventions.

oor control of trunk postural muscles is a primary impairment in people with cerebral palsy (CP).1–3 To date, the majority of work investigating postural control in CP has done so indirectly by studying lower-extremity muscle responses to balance perturbations and center-of-pressure (COP) trajectories during standing and walking or focused primarily on sitting postural control.3,4 Direct study of trunk and hip muscle activity during upright movement is desirable in CP because impairments in postural muscle function are associated with upright functional activity limitations and participation restrictions in various populations5–7 and treatments to improve trunk and hip muscle activation may increase functional ability.

The majority of gait research in CP includes participants who are between the ages of 6 years and adolescence. Recent neurorehabilitation research emphasizes the importance of early and intensive intervention after central nervous system damage to best promote neuroplasticity.12–14 If these concepts are to be applied to individuals with CP, with interventions targeted earlier after the neural insult, more knowledge is needed about motor control and the neural activation of muscles in younger children with CP than are typically studied. For this study, the function of trunk and hip muscles in young children is of particular interest.

Poor postural control in people with CP may be a direct expression of the neural insult or the result of compensations for other primary impairments, such as altered muscle tone (resistance to stretch) and deficits in neuromuscular activation. Poor postural control can cause secondary compensation by other muscles to assist in providing postural stability, reducing the effectiveness of muscles that typically function as primary movers of the extremities.8 Evidence to support this notion includes observations that children with CP have greater ambulatory ability when the distal limb musculature is primarily affected and proximal limb musculature is less affected.9,10 In addition, compared with knee and ankle muscles, the strength (force-generating capacity) of the hip abductors in children with CP explained the largest variance in gait and gross motor function.11 Given the importance of postural control for functional mobility and the limitations associated with impairments in trunk and hip muscles in people with CP, direct investigation of the activation patterns of trunk and hip

Electromyographic (EMG) analysis is an important component in the examination of muscle function in people with CP. Several factors can be extracted from the EMG signal to provide insight into muscle activation patterns.9,15,16 The most common clinical use of muscle EMG analysis is to determine the onset and offset timing of muscle activity during movement. This type of temporal information identifies periods of muscle activity and inactivity throughout the gait cycle and can be used to determine coactivation of antagonistic muscle groups. The primary objective of this study was to investigate differences in the timing characteristics of trunk and hip muscle activity during walking in young children with CP compared with children with typical development (TD). Identifying early deficits in postural muscle function in individuals with CP may lead to the development of more direct interventions that have the potential to improve postural control before compensatory postural motor strategies are reinforced. A secondary objective was to report typical activity patterns in

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the trunk and hip muscles in young children with TD.

Method Participants Participants with CP were recruited through the CP clinics at the Shriners Hospital for Children in Philadelphia, Pennsylvania, the Children’s Specialized Hospital in Mountainside, New Jersey, and other local rehabilitation facilities. Participants with TD were recruited from siblings of the participants with CP, from children of people known to the investigators, and from a local day care center. All data collection procedures were explained, and parents gave their informed consent to the research and to publication of the results. Assent of a minor also was obtained from participants who were 7 years of age or older. The inclusion criteria for all children were: 0.5 to 60 months of walking experience, ability to ambulate barefoot at least 4.6 m (15 ft) with supervision (children with CP could use their usual assistive device [ie, crutches or walker without pelvic guide] if it did not stabilize or restrict movement of the trunk or pelvis), and the ability to follow 1-step verbal directions. Children with CP additionally had a diagnosis of spastic diplegia or quadriplegia and a Gross Motor Function Classification System (GMFCS) level of II or III.17 Children were not considered for the study if they had a lower-extremity fracture or surgery in the previous 12

Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on April 29, 2010, at ptjournal.apta.org.

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Muscle Activation Patterns During Walking in Children months, a botulinum toxin injection in the previous 6 months, or a history of dorsal rhizotomy or lowerextremity tendon transfer.

months, was calculated as the difference between the participant’s age on the day of the study and the age at onset of walking.

The selection of months of walking experience rather than age as a primary inclusion criterion was based on reports that experience is a stronger predictor of walking and balance skill than age in early walkers.18,19 The onset of walking was operationally defined as the age when the child was able to take at least 3 continuous, independent steps (without assistance of another person, but may have been with an assistive device).20 Walking experience, in

Procedure Anthropometric measurement. All anthropometric measurements were taken by the same pediatric physical therapist and included height, seated height, weight, and bilateral leg length (anterior superior iliac spine to the apex of the medial malleolus). All anthropometric lengths were measured with a Harpenden anthropometer,* with the exception of those in 2 children who were fearful of the device. For these children, a

The Bottom Line What do we already know about this topic? Individuals with spastic cerebral palsy (CP) demonstrate excessive activation of lower-extremity muscles during walking. Although impairment of postural control is a primary characteristic of CP, the muscle activation patterns of the postural muscles during walking are unknown in both children with CP and children with typical development.

What new information does this study offer? Young children with CP demonstrated differences in the timing patterns of muscle activation during walking for the trapezius, erector spinae, rectus abdominis, external oblique, gluteus maximus, gluteus medius, rectus femoris, and semitendinosus muscles. Children with CP also demonstrated greater total muscle activation and coactivation in all muscles studied except the external oblique. This excessive activity was characterized by early onset and late cessation of activity in the external oblique, gluteus maximus, and gluteus medius muscles, and by continuous activation in the trapezius, erector spinae, rectus femoris, and semitendinosus muscles.

If you’re a patient, what might these findings mean for you? Young children with CP may benefit from treatments that focus on improving the coordination of trunk and hip muscles during walking, and from treatments that focus on reducing the amount of time those muscles are active during the walking cycle. However, specific treatments with these goals have not yet been investigated.

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standard tape measure was used in lieu of the anthropometer. EMG instrumentation. Surface EMG data from trunk, gluteal, and thigh muscles were acquired using a 16-channel recording system (Myomonitor III and trigger module†) with preamplified silver-silver chloride parallel bar surface electrodes with a 10.0-mm interelectrode distance. The EMG data were collected at 1,200 Hz, preamplified with a gain of 10, and band-pass filtered between 20 and 450 Hz. The EMG data were collected from 8 muscles bilaterally: trapezius (TZ), erector spinae (ES), rectus abdominis (RA), external oblique (EO), gluteus maximus (GMx), gluteus medius (GMd), rectus femoris (RF), and semitendinosus (ST) (Tab. 1). The RF and ST were chosen in addition to the trunk and gluteal muscles because these muscles anatomically cross the hip joint. Sensor placement for the abdominal muscles was determined using the methods described by Ng et al.21 Sensor placement for all other muscles (back, gluteal, and thigh) was determined in accordance with the SENIAM project recommendations (Tab. 1).22 The skin areas were cleaned with alcohol, and the sensors were affixed to the skin with double-sided adhesive. The electrodes were further secured using hypoallergenic tape or a flexible, latex-free, nonadhesive wrap (Coflex-NL‡) encircling the waist and thighs. Self-adhesive reference electrodes§ were placed on the skin over the patella bilaterally. A

* Holtain Ltd, Crosswell, Crymych, Pembs, SA41 3UF United Kingdom. † Delsys Inc, PO Box 15734, Boston, MA 02215. ‡ Andover Healthcare Inc, 9 Fanaras Dr, Salisbury, MA 01952. § Axelgaard Manufacturing Co Ltd, Lystrup 8520, Denmark.

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Muscle Activation Patterns During Walking in Children volitional contraction of each muscle, when possible, was elicited to verify placement and confirm the absence of electrical activity from an adjacent muscle. The children were asked to perform specific movements to elicit the corresponding muscle contractions, such as leaning backward in a sitting position to activate the RA muscles or standing on one leg (with hands held, if needed) to activate the GMd muscles. Data from 2 static baseline EMG trials were collected prior to the walking trials to establish baseline muscle activity. For these trials, the child lay still in a supine position for 5 seconds. The trial with the least muscle activity was selected for postprocessing. Walking trials. Children walked barefoot down an instrumented walkway (GAITRite㛳) at a selfselected pace. Data from 3 to 5 trials, each consisting of at least 4 consecutive footfalls, were collected, depending on participant tolerance and fatigue. Start and stop targets were placed on the floor approximately 1.5 m (5 ft) beyond either end of the instrumented walkway to minimize acceleration or deceleration while walking on the walkway. A walking trial was started by having the child stand on the start target. Data collection was initiated through the GAITRite software, which triggered EMG collection through a trigger module† for synchronous recording. The child then was instructed to walk to the target beyond the opposite end of the walkway. Children had the opportunity to sit on a chair between walking trials to minimize fatigue. During the walking trials, the EMG preamplification unit, which typically is worn on a backpack, was 㛳

CIR Systems, 60 Garlor Dr, Havertown, PA 19083.

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Table 1. Electromyogram Sensor Locations Muscle Trapezius

(middle)22

Sensor Location 50% of the distance from the medial border of the scapula to the T3 spinous process, parallel to the line from T5 to the acromion

Erector spinae (longissimus)22

1–2 finger widths lateral from the L1 spinous process, oriented vertically

Rectus abdominis21

At the level of the anterior superior iliac spine, 1–2 cm lateral to the midline, oriented vertically

External oblique21

Just below the rib cage at the inferior angle of the ribs, oriented obliquely

Gluteus maximus22

50% of the distance from the sacral vertebrae to the greater trochanter, at the greatest prominence of the middle buttocks, parallel to a line from the posterior superior iliac spine to the middle posterior thigh

Gluteus medius22

In a side-lying position, 50% of the distance from the iliac crest to the greater trochanter, parallel to this axis

Quadriceps femoris (rectus femoris)22

50% of the distance from the anterior superior iliac spine to the superior patella, parallel to this axis

Semitendinosus22

50% of the distance from the ischial tuberosity to the medial tibial epicondyle, parallel to this axis

carried behind all participants by an assistant so as not to add weight that could affect muscle activity in the smaller children. If needed, children were motivated and rewarded with stickers, small snacks, or favorite toys. Walking trials were videotaped for later gait cycle selection, and parents or caregivers signed a separate consent statement to allow videotaping. Because this was an observational study that attempted to describe the natural pattern of muscle activation at equivalent levels of walking experience, walking speed was not controlled. The majority of children with CP are unable to match the walking speed of children with TD; therefore, the only reasonable method to control for speed would be for the children with TD to walk at greatly reduced speeds. In addition to being a difficult task to have young children (TD group’s mean age⫽39.7 months) walk at a steady state at target slow speeds, purposely altering walking speed to walk slowly (within individuals) has been shown

to significantly alter typical muscle activation patterns, to a greater extent than walking at fast speeds and particularly in proximal muscles.23,24 This method would have confounded the secondary objective of this study (ie, to report typical, unaltered patterns in trunk and hip muscles for young children with TD). Data Analysis Video footage of each trial was reviewed to determine the most appropriate gait cycles to select for data analysis. Ten gait cycles (5 left, 5 right) were selected based on the observation of each individual’s typical walking pattern (walking without distractions, pauses, or moving arms toward an object). The 10 selected gait cycles were extracted from the EMG files using the timesynchronized marker data (initial foot contact for consecutive footfalls) collected from the instrumented walkway. Stance phase was identified as the period from initial foot contact to ipsilateral toe-off. Swing phase was identified as the period from toe-off to subsequent

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1.10 (0.14), 0.75–1.32 16.5 (2.2), 11.2–22.9 0.56 (0.06), 0.46–0.69 17.3 (5.4), 10.0–31.2 28.5 (18.1), 1.0–60.0 31 22.9 (13.8), 8.0–55.0 Total

a

15 34.8 (10.2),* 18.0–55.0

Data reported as mean (SD), range of values. TD⫽typically developing, CP⫽cerebral palsy, M⫽male, F⫽female, BMI⫽body mass index. Asterisks indicate a significant difference from the TD group (P⬍.05).

1.06 (0.14), 0.83–1.32 17.2 (2.4), 14.7–22.9 0.56 (0.06), 0.48–0.65 19.6 (5.9),* 10.9–31.2

14 F, 17 M 51.0 (24.1), 13.0–108.0

0.97 (0.13), 0.75–1.18 15.9 (1.8), 11.2–18.8 0.55 (0.06), 0.46–0.69 15.1 (3.9), 10.0–21.9

63.1 (23.2),* 25.0–108.0

39.7 (19.5), 13.0–67.5 9 F, 7 M

5 F, 10 M 28.4 (17.0), 2.0–60.0

28.6 (19.6), 1.0–58.0 16 11.7 (3.1), 8.0–20.0

CP

Onset of Walking (mo)

TD

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Demographic and Anthropometric Dataa

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Sex

Age (mo)

Weight (kg)

Height (m)

BMI (kg/m2)

Seated Height (m)

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foot contact. The EMG data were processed using custom-written programs in MATLAB software.# All signals were normalized to 1,000 points, representing the gait cycle from 0% to 100% in 0.1% increments.

muscle was active in both the CP and TD groups. Assuming unequal variance between groups, MannWhitney U tests were used to determine differences in percent activation and coactivation (P⬍.05).

To identify muscle activity throughout the selected gait cycles, the Teager-Kaiser energy operator was applied to the EMG data.25 This method uses both the amplitude and frequency components of the signal and was found to better detect the onset of muscle activity than a standard amplitude threshold method.26,27 The EMG data from the selected gait cycles for each participant were filtered with a second-order, low-pass Butterworth filter with phase correction and a cutoff frequency of 10 Hz and averaged across cycles. To determine the onset/offset threshold, the TeagerKaiser energy operator was applied to the static EMG baseline signal. The resulting output then was rectified, and the mean and standard deviation were calculated. The mean, plus 1 standard deviation, was used as the threshold above which defined muscle activity during walking.

An additional analysis was performed to determine when during the gait cycle muscle activity varied between groups. For this analysis, the gait cycle was reduced to 100 points (1% increments), and the number of children in each group who had activity in the muscle at each point in the gait cycle was determined. The chi-square test was performed at each point in the gait cycle to determine whether significant differences (P⬍.05) existed between groups in the number of children who had activity in the particular muscle.28 All statistical analyses were performed using SPSS software, version 11.0.**

Total activation and coactivation first were analyzed as a percent of the gait cycle. A percent of the gait cycle for activation was calculated for each muscle by summing the duration (in percents) of all periods of muscle activity. Coactivation was determined by calculating the total time (in percents) antagonistic muscles were simultaneously active. Coactivation was calculated for the ipsilateral RA-ES and RF-ST muscle pairs. Group means were calculated for percent muscle activation and coactivation, from which 95% confidence intervals (CIs) were determined. These measures allowed for comparison of total relative time a particular # The Mathworks Inc, 3 Apple Hill Dr, Natick, MA 01760.

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Role of the Funding Sources Direct costs for this study, including data acquisition equipment, supplies, travel to data collection sites, and consultant fees, were funded by a Clinical Research Grant to Dr Prosser from the Section on Pediatrics, American Physical Therapy Association. A National Institute of Neurological Disorders and Stroke grant (R03NS048875) to Dr Lauer funded the time of the principal investigator and a coinvestigator and costs related to dissemination. A National Institute of Child Health and Human Development grant (R01HD043859) to Dr Lee funded the time of a coinvestigator and research aides. This research also was supported, in part, by the Intramural Research Program of the Clinical Center, National Institutes of Health.

** SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Results A power analysis was performed after the initial 9 children (6 with TD, 3 with CP) completed the study. A sample size of 8 to 28 individuals (4 –14 in each group) was predicted to power individual muscle activity variables to 0.80 or greater at the P⬍.05 level of significance. The maximum sample was used to adequately power all variables, and data were collected from an additional 20% (6 children) to account for anticipated difficulties with participant tolerance and for cases of unusable data. Thus, a total of 34 children were enrolled in this study. Data from 3 children were excluded (1 child had a questionable diagnosis of CP, and 2 children were unable to walk without additional assistance from an investigator during the testing session). Data for the remaining 31 children (17 male, 14 female; 15 with CP, 16 with TD) were used for analysis. Walking experience did not differ between groups (P⫽.969). The children with CP were heavier (P⫽.017) and had longer legs (P⫽.029) than the children with TD due to a later onset of walking and, therefore, were older at the time of testing. In the group of children with CP, 7 were classified as GMFCS level II, and 8 were classified as level III. One child was classified as spastic quadriplegic, and 14 children were classified as spastic diplegic. Three children walked without assistive devices, 9 used posterior rolling walkers, 1 used bilateral forearm crutches, and 2 used unilateral forearm crutches. Data for range of motion were not obtained from 1 child with CP due to time constraints. Demographic and anthropometric data are provided in Table 2. Walking speed was normalized using leg length as per Hof29 and was 0.22 (SD⫽0.10) for the CP group and 0.42 (SD⫽0.06) for the TD group.

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Figure 1. Mean total percent activation of trunk and hip muscles for children with cerebral palsy (CP) and children with typical development (TD). Bars represent upper and lower bounds of 95% confidence intervals. Asterisks indicate muscles that were significantly higher in the CP group compared with the TD group. TZ⫽trapezius, ES⫽erector spinae, RA⫽rectus abdominis, EO⫽external oblique, GMx⫽gluteus maximus, GMd⫽gluteus medius, RF⫽rectus femoris, and ST⫽semitendinosus.

Muscle activation from left and right sides did not differ within groups; thus, left-side and right-side data were pooled for percent total activation and coactivation. The CP group had significantly more total activation time for each muscle (ranging from P⬍.001 to P⫽.024), except for the EO, which was not different from that of the TD group (P⫽.593). Group means for activation, including 95% CIs, are shown in Figure 1. The CP group also had significantly more total coactivation time for both the RA-ES muscle pair (P⫽.007) and the RF-ST muscle pair (P⬍.001). Coactivation for the RA-ES muscle pair averaged 20% (95% CI⫽5%–36%) for the CP group and 1% (95% CI⫽0%– 3%) for the TD group. Coactivation for the RF-ST muscle pair averaged 75% (95% CI⫽61%– 89%) for the CP group and 20% (95% CI⫽10%–30%) for the TD group. To determine where in the gait cycle the children with CP had excessive muscle activity, histograms were generated to show the number of active muscles at each point in the gait cycle. No meaningful differences existed between left and right sides in number of active muscles or in

percent stance time (57% in the TD group, 59% in the CP group) or percent swing time. However, because of potential differences in left and right symmetry within individuals (eg, left side active, right side not active) and the inability to average these nominal data, each side was counted individually, resulting in a maximum count of 30 muscles for the CP group and 32 muscles for the TD group. Figure 2 shows histograms for each muscle for both groups. The asterisks in the figure identify the ranges in the gait cycle when the CP group had significantly more active muscles compared with the TD group, as determined by the chi-square tests. The TZ was active in more children in the CP group compared with the TD group throughout the majority of the gait cycle, except for the period from mid-stance to late stance. The ES was active in more children in the CP group from just prior to initial contact through mid-stance. The RA also was active in more children in the CP group throughout most of the gait cycle. There were no differences in EO activity between groups at any point in the stride. The GMx was active in more children in the CP group during

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Muscle Activation Patterns During Walking in Children both the stance and swing phases of gait, but not during the transitions between the phases. The GMd and ST were active in more children in the CP group from mid-stance through early swing. Except for a short period of time around initial contact, the RF was active in more children in the CP group throughout the gait cycle. A summary figure was generated from the histograms to summarize the periods of activity for each muscle in each group. Each group was considered to have activity at a particular point in the gait cycle if the number of active muscles was at least one half of the total number of muscles at that point (15/30 for the CP group, 16/32 for the TD group). Figure 3 shows the generalized periods of activity for each muscle in each group. The EO had several points in the gait cycle for each group when activity was present for one less than one half of the total number of muscles. Because these points were in the midst of large periods of activity, they were included within those periods of activation. The TZ, ES, RF, and ST demonstrated activity throughout the gait cycle in the majority of children with CP. The EO, GMx, and GMd demonstrated similar phases of activity in the CP group compared with the TD group, but these muscles demonstrated longer periods of activation in the CP group, including both earlier onset and delayed offset of activity. Although the RA demonstrated more total muscle activation in the CP group compared with the TD group, it was not active in most children with CP throughout the gait cycle. Figure 2. Histograms for number of active muscles at each point in the gait cycle (1% increments) in children with typical development (TD) and children with cerebral palsy (CP). Left and right sides were counted individually, for a maximum of 32 in the TD group and 30 in the CP group. Thick vertical lines indicate toe-off, the transition from stance phase to swing phase (57% of the gait cycle in the TD group, 59% of the gait cycle in the CP group). Asterisks indicate periods of activity where the CP group had significantly more active muscles than the TD group. TZ⫽trapezius, ES⫽erector spinae, RA⫽rectus abdominis, EO⫽external oblique, GMx⫽gluteus maximus, GMd⫽gluteus medius, RF⫽rectus femoris, and ST⫽semitendinosus.

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Discussion This study is the first to investigate muscle activation patterns of the trunk and hip muscles during walking in children with TD and children with CP. It also demonstrates the use of quantitative methods of analyzing EMG signals to determine periods of July 2010

Muscle Activation Patterns During Walking in Children activity and inactivity across the gait cycle. Increased activity for the CP group was observed as prolonged durations of bursts of activity and muscles that were continuously activated throughout the gait cycle compared with the TD group. Even for the EO, which was not significantly different between groups for total muscle activity, more than half of the CP group had activity during 80% of the gait cycle compared with 39% of the gait cycle in the TD group. Excessive muscle activity has been reported in the lower-extremity muscles in children with CP.10,30 In these studies, however, the children with CP were compared with children with TD of the same age who had more walking experience because walking onset is delayed in children with CP. Children with TD who have less walking experience are known to have more muscle activity than children with TD who have more walking experience.31 Using walking experience, not age, for inclusion in this study is a novel approach to control for the improvement in walking ability that occurs with practice after the onset of walking. The increased muscle activity in the CP group in this study, however, was present even as the groups were compared by walking experience rather than age. The patterns of muscle activity in the GMd and ST in the TD group were consistent with those reported previously by Sutherland and colleagues31 in their study of more than 300 children between the ages of 1 and 7 years. The period of activity in the GMx in our study was slightly shorter than that reported in the study by Sutherland and colleagues. This difference can likely be attributed to differences between the 2 studies in the methods used to determine activation. Sutherland and colleagues used visual inspection of the raw EMG signals, whereas we used July 2010

Figure 3. Muscle activity during the gait cycle in children with typical development (TD) and children with cerebral palsy (CP). Dashed vertical lines indicate toe-off, the transition from stance phase to swing phase (57% of the gait cycle in the TD group, 59% of the gait cycle in the CP group). TZ⫽trapezius, ES⫽erector spinae, RA⫽rectus abdominis, EO⫽external oblique, GMx⫽gluteus maximus, GMd⫽gluteus medius, RF⫽rectus femoris, and ST⫽semitendinosus.

advanced processing methods and objective rules to determine activation patterns. Although the GMd, ST, and GMx were the only muscles in the current study for which activation patterns have been reported previously for young children with TD, muscle activity patterns during walking have been shown to approximate adult patterns after the age of 3 years.31 For this reason, comparison of data for the other muscles included in this study with data from adults is justified. Timing patterns of activity for the RF, as well as the gluteal muscles, in the TD group are consistent with those reported in adults.32 White and McNair33 investigated patterns of activity in the ES, RA, and EO in adults. They did not use a threshold to determine the timing of muscle activity onset and offset, but rather identified different patterns by averaging normalized amplitude curves across participants. Therefore, exact comparison is not possible, but areas of increased normalized amplitude for the ES and EO in their study do cor-

respond to periods of activity for the ES and EO in the TD group in the current study. Also similar to the TD group in the current study, the majority of adult participants in the study by White and McNair did not have periods of activity above baseline in the RA. The comparison of TD muscle activity data from the current study with data from the studies mentioned above demonstrates that, similar to lower-extremity muscles, activation patterns of the trunk muscles approximate those of adult patterns by a young age. As expected, self-selected walking speed was slower in the CP group than in the TD group. It is possible that differences in walking speed between the groups had some effect on the current results. However, previous studies24,34 have shown significant changes in EMG signal amplitude with changes in walking speed, but little effect on the timing of muscle activation at speeds similar to that of the current CP group (0.50 m/s). In contrast, one study23 showed increased proximal muscle

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Muscle Activation Patterns During Walking in Children coactivation at “very slow” speeds, slower than that of the current CP group. However, comparison of the current data with the data from these studies using adults walking at fixed speeds is problematic because the speeds were not normalized for body size. Similar muscle activity timing patterns were reported in children 3 years of age and older compared with adults, despite a significantly slower walking speed.31 If the fixed speeds in these comparison studies were adjusted for children, it is likely that even fewer or no differences in activation and coactivation timing would have been observed at speeds comparable to those of the current CP group. Furthermore, even with normalization of walking speeds, caution must be taken because studies to date have investigated only differences within individuals and not across specific diagnostic groups. To our knowledge, only Schwartz et al35 have investigated the effect of walking speed on muscle activity patterns in children with TD. As in our work, Schwartz and colleagues did not enforce fixed speeds due to concerns about alterations in typical gait patterns that may occur if the individuals were paced. Instead, they instructed children to walk at “very slow,” “slow,” and “fast” speeds, and they later classified normalized walking speeds based on the number of standard deviations from each individual’s self-selected speed. In our study, the CP group walked at speeds equivalent to the slow speed in the study by Schwartz and colleagues. Although EMG amplitude generally decreased at slow and very slow speeds in the study by Schwartz and colleagues, the most notable difference in a comparable muscle was seen in the RF, which demonstrated relative inactivity at the slow speeds in the study by Schwartz and colleagues. This result is counter to the results of the current study, in which 994

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constant activity was observed in the RF in the slow-walking CP group, further emphasizing the excessive activity in the CP group. However, research is needed to understand the effects of slow and fast walking speeds specifically in children with CP. Despite our use of automated EMG processing techniques and objective rules to determine the duration of muscle activity in each group, there remains no flawless method to analyze EMG signals, particularly in children with neurological impairments. Unlike the larger and thicker muscles of the thigh and gluteal region, the superficial muscles of the trunk are thin, and the recording sensors may have recorded some activity from the underlying muscles. The internal oblique, rhomboids, and transverse abdominis muscles are directly deep to the sensor location for the EO, TZ, and RA, respectively. The ES was recorded from a location that is deep to the broad superficial fascia of the latissimus dorsi muscle. The use of fine-wire needle EMG electrodes would avoid this potential issue, but application in young children has clear feasibility and ethical limitations. Additionally, needle electrodes record only from a single or small group of motor units, and as a result, the recorded signal may not be representative of the activity of the entire muscle.36 An additional limitation exists in the comparison of muscle activity between the TD and CP groups, especially for the TZ, because the majority (12/15) of the children in the CP group used an assistive device for walking. The mean percent activation of the TZ in the children with CP who used an assistive device was 90%. Of the 3 children with CP who did not use an assistive device, 1 child had activation similar to the device-using mean (88%), and the other 2 children had far less activa-

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tion (22% and 11%) than both the device-using mean and the TD group mean (45%). Although these limited data are inconclusive, it is possible that use of an assistive device alone may have contributed to greater activation of the TZ in some children in the CP group. The TZ may be activated during forward movement of and bearing weight through the assistive device. Use of a device may have additionally affected the activation timing of other muscles. This issue is difficult to avoid when studying young children with CP. According to the GMFCS classification,17 only children classified as level I (least impaired) begin to walk without the use of any assistive device. Children classified as level II walk with an assistive device for the first few years of walking, then later do not require a device. Children classified as level III require an assistive device for functional ambulation. Therefore, to study any children with greater severity of CP than those who are least impaired (GMFCS level I) during the early years of walking, the use of walking aids must be allowed. We briefly considered collecting data from trials with the TD group using assistive devices to control for this difference. Walking with an assistive device, however, would have been a novel task for the children with TD, and there are well-known differences in the timing and magnitude of muscle activation during novel tasks.37 Future work could include several CP groups, classified by GMFCS level, gait pattern, the particular assistive device used, and investigate various walking speeds. Finally, although the use of an assistive device may affect muscle activation in addition to motor control differences, it is important to recognize that the children with CP use more postural muscle effort in daily walking than their peers, indifferent of the cause, which is important from cardiovasJuly 2010

Muscle Activation Patterns During Walking in Children cular endurance, muscular fatigue, shoulder kinetics, and biomechanical efficiency perspectives. A final limitation is the consideration that, although the groups had equal time since the onset of walking (walking experience), the amount of walking practice was still likely to be higher in the TD group. After the onset of walking, walking quickly becomes the primary means of mobility for children with TD. Children with CP often practice walking only in therapy sessions or during more structured periods of practice at home. Even when of school age, children with CP take fewer steps per day than children with TD.38 As a measure of neural activation of skeletal muscle, surface EMG is a noninvasive, indirect measure of motor control. An understanding of neuromuscular control is useful to inform clinicians and researchers of the specific impairments that contribute to functional activity limitations and participation restrictions. Specifically, making clinical decisions to treat patients with deficits in postural control requires an understanding of the causes of poor postural control. Reducing excessive postural muscle activity and improving coordination and reciprocation among postural muscles in people with CP might be accomplished through task-specific, repeated practice paradigms, biofeedback, electrical stimulation, pharmacological agents, or exercise. Several other studies39 – 43 have examined postural control in people with CP during static standing, during reaching, and during external perturbation balance testing. These studies demonstrated increased coactivation, prolonged latency of activation, altered muscle recruitment order following perturbations, and continuous activation of lowerextremity and postural muscles. The July 2010

present study demonstrated similar findings for muscle activation during walking, including increased coactivation and continuous activation of postural muscles. With the exception of the RA and GMx, all muscles in the CP group were active over 75% of the gait cycle. This excess activation may create a functionally rigid trunk, which may restrict the child’s ability to make fine adjustments to trunk position relative to the lower extremities and the environment and constrain the therapist’s ability to grade muscle activity in response to external perturbations.4 Roerdink and colleagues44 reported that, after a stroke, individuals had less stability but also more regularity in frontalplane COP trajectories during standing compared with their peers who were healthy. With recovery and rehabilitation, COP trajectories became less regular. They suggested that, after stroke, the participants attempted to limit variations in COP in order to decrease the degrees of freedom that they must control and that the individuals were better able to control multiple degrees of freedom after rehabilitation. A similar strategy may occur in young children with CP. Hsue and reported reduced colleagues45 anterior-posterior displacements of COP and center of mass (COM) during walking in children with CP. Limiting excursion and variability in COP and COM by excessively activating muscles of the trunk and hips may be a strategy that children with CP use to maintain upright posture against gravity and move the body forward, despite the multitude of neurological impairments limiting typical movement patterns. Excessive muscle activation may be a compensation for poor control of postural muscles and may limit the ability to precisely control changes in their body’s COM during dynamic

movements. If increased irregularity of COP trajectories is a favorable result of rehabilitation after stroke (as in the study by Roerdink and colleagues), perhaps interventions that aim to completely reduce static standing postural sway in people with CP should be closely reexamined, and training to encourage controlled postural sway in all directions should be investigated. Current therapeutic, medical, and surgical treatment for people with CP focuses on upper- and lowerextremity interventions for spasticity (hypertonicity) management, musculoskeletal abnormalities, and functional training.46,47 The results of this study suggest that postural muscle control training should be investigated to address impairments of the trunk and to encourage the development of more functional, reciprocal, and efficient movement strategies in children with CP. Core muscle control is related to athletic performance and function in adults who are healthy,48,49 and improving core muscle control may have promise in people with CP.50 Strategies to increase the child’s ability to control greater variations in trunk movement through phasic trunk muscle coordination, rather than constant muscle activity, may encourage more effective and efficient patterns of postural muscle control, which, in turn, may encourage more efficient patterns of movement in the upper and lower extremities. All authors provided concept/idea/research design and reviewed the manuscript prior to submission. Dr Prosser, Dr Lee, Dr VanSant, and Dr Lauer provided writing and facilities/ equipment. Dr Prosser provided data collection, project management, and participants. Dr Prosser, Dr Lee, and Dr Lauer provided data analysis and fund procurement. The authors thank Steve Capella and Jenny Lee for their assistance with data collection and Diana Deshefy, PT, DPT, Samuel Pierce, PT, PhD, and Erin Sheeder, PT, DPT, for assistance with participant recruitment.

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Muscle Activation Patterns During Walking in Children Preliminary results of this study were included in a poster presentation at the Combined Sections Meeting of the American Physical Therapy Association; February 9 –12, 2009; Las Vegas, Nevada. The Institutional Review Board of Temple University Hospital (for Shriners Hospital) and the institutional review boards of the additional data collection sites approved all procedures. Direct costs for this study, incuding data acquisition equipment, supplies, travel to data collection sites, and consultant fees, were funded by a Clinical Research Grant to Dr Prosser from the Section on Pediatrics, American Physical Therapy Association. A National Institute of Neurological Disorders and Stroke grant (R03NS048875) to Dr Lauer funded the time of the principal investigator and a coinvestigator and costs related to dissemination. A National Institute of Child Health and Human Development grant (R01HD043859) to Dr Lee funded the time of a coinvestigator and research aides. This research also was supported, in part, by the Intramural Research Program of the Clinical Center, National Institutes of Health. This article was submitted May 15, 2009, and was accepted March 22, 2010. DOI: 10.2522/ptj.20090161

References 1 Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy, April 2006. Dev Med Child Neurol Suppl. 2007;109:8 –14. 2 Davis MF, Worden K, Clawson D, et al. Confirmatory factor analysis in osteopathic medicine: fascial and spinal motion restrictions as correlates of muscle spasticity in children with cerebral palsy. J Am Osteopath Assoc. 2007;107:226 – 232. 3 van der Heide JC, Hadders-Algra M. Postural muscle dyscoordination in children with cerebral palsy. Neural Plasticity. 2005;12:197–203. 4 Woollacott MH, Crenna P. Postural control in standing and walking in children with cerebral palsy. In: Hadders-Algra M, Carlberg EB, eds. Postural Control: A Key Issue in Developmental Disorders. London, United Kingdom: Mac Keith Press; 2008: 97–130. 5 Lin SI, Woollacott MH, Jensen JL. Postural response in older adults with different levels of functional balance capacity. Aging Clin Exp Res. 2004;16:369 –374. 6 Era P, Avlund K, Jokela J, et al. Postural balance and self-reported functional ability in 75-year-old men and women: a crossnational comparative study. J Am Geriatr Soc. 1997;45:21–29.

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7 Liao HF, Hwang AW. Relations of balance function and gross motor ability for children with cerebral palsy. Percept Mot Skills. 2003;96(3 pt 2):1173–1184. 8 Nicholson JH, Morton RE, Attfield S, Rennie D. Assessment of upper-limb function and movement in children with cerebral palsy wearing lycra garments. Dev Med Child Neurol. 2001;43:384 –391. 9 Lauer RT, Stackhouse CA, Shewokis PA, et al. A time-frequency based electromyographic analysis technique for use in cerebral palsy. Gait Posture. 2007;26: 420 – 427. 10 Policy JF, Torburn L, Rinsky LA, Rose J. Electromyographic test to differentiate mild diplegic cerebral palsy and idiopathic toe-walking. J Pediatr Orthop. 2001;21: 784 –789. 11 Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88:1114 –1120. 12 Nudo RJ. Adaptive plasticity in motor cortex: implications for rehabilitation after brain injury. J Rehabil Med. 2003; 41(suppl):7–10. 13 Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005; 86(12 suppl 2):S101–S114. 14 Dobkin B, Barbeau H, Deforge D, et al. The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial. Neurorehabil Neural Repair. 2007;21:25–35. 15 Hodges PW, Bui BH. A comparison of computer-based methods for the determination of onset of muscle contraction using electromyography. Electroencephalogr Clin Neurophysiol. 1996;101:511– 519. 16 Roetenberg D, Buurke JH, Veltink PH, et al. Surface electromyography analysis for variable gait. Gait Posture. 2003;18: 109 –117. 17 Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214 –223. 18 Adolph KE, Vereijken B, Shrout PE. What changes in infant walking and why. Child Dev. 2003;74:475– 497. 19 Sundermier L, Woollacott MH, Roncesvalles N, Jensen J. The development of balance control in children: comparisons of EMG and kinetic variables and chronological and developmental groupings. Exp Brain Res. 2001;136:340 –350. 20 Wu J, Looper J, Ulrich BD, et al. Exploring effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome. Dev Med Child Neurol. 2007;49:839 –945.

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21 Ng JK, Kippers V, Richardson CA. Muscle fibre orientation of abdominal muscles and suggested surface EMG electrode positions. Electromyogr Clin Neurophysiol. 1998;38:51–58. 22 Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10:361–374. 23 Nymark JR, Balmer SJ, Melis EH, et al. Electromyographic and kinematic nondisabled gait differences at extremely slow overground and treadmill walking speeds. J Rehabil Res Dev. 2005;42:523–534. 24 van Hedel HJ, Tomatis L, Muller R. Modulation of leg muscle activity and gait kinematics by walking speed and bodyweight unloading. Gait Posture. 2006;24:35– 45. 25 Li X, Zhou P, Aruin AS. Teager-Kaiser energy operation of surface EMG improves muscle activity onset detection. Ann Biomed Eng. 2007;35:1532–1538. 26 Solnik S, DeVita P, Rider P, et al. TeagerKaiser operator improves the accuracy of EMG onset detection independent of signal-to-noise ratio. Acta Bioeng Biomech. 2008;10:65– 68. 27 Lauer RT, Prosser LA. Use of the TeagerKaiser energy operator for muscle activity detection in children. Ann Biomed Eng. 2009;37:1584 –1593. 28 Portney LG, Watkins MP. Foundations of Clinical Research, Applications to Practice. Stamford, CT: Appleton & Lange; 1993. 29 Hof AL. Scaling gait data to body size. Gait Posture. 1996;4:222–223. 30 Unnithan VB, Dowling JJ, Frost G, et al. Co-contraction and phasic activity during gait in children with cerebral palsy. Electromyogr Clin Neurophysiol. 1996;36: 487– 494. 31 Sutherland D, Olshen R, Biden E, Wyatt M. The Development of Mature Walking. London, United Kingdom: Cambridge University Press; 1988. 32 Soderberg GL, Knutson LM. EMG methodology. In: Craik RL, Oatis CA, eds. Gait Analysis: Theory and Application. St Louis, MO: Mosby; 1995:293–306. 33 White SG, McNair PJ. Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to identify patterns of activity. Clin Biomech (Bristol, Avon). 2002;17:177–184. 34 Den Otter AR, Geurts AC, Mulder T, Duysens J. Speed related changes in muscle activity from normal to very slow walking speeds. Gait Posture. 2004;19:270 – 278. 35 Schwartz MH, Rozumalski A, Trost JP. The effect of walking speed on the gait of typically developing children. J Biomech. 2008;41:1639 –1650. 36 Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic electromyographic data. Phys Ther. 2000;80: 485– 498.

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Muscle Activation Patterns During Walking in Children 37 Vorro J, Hobart D. Kinematic and myoelectric analysis of skill acquisition, I: 90-cm subject group. Arch Phys Med Rehabil. 1981;62:575–582. 38 Bjornson KF, Belza B, Kartin D, et al. Ambulatory physical activity performance in youth with cerebral palsy and youth who are developing typically. Phys Ther. 2007; 87:248 –257. 39 Ferdjallah M, Harris GF, Smith P, Wertsch JJ. Analysis of postural control synergies during quiet standing in healthy children and children with cerebral palsy. Clin Biomech (Bristol, Avon). 2002;17:203–210. 40 van der Heide JC, Begeer C, Fock JM, et al. Postural control during reaching in preterm children with cerebral palsy. Dev Med Child Neurol. 2004;46:253–266. 41 Hadders-Algra M, van der Fits IB, Stremmelaar EF, Touwen BC. Development of postural adjustments during reaching in infants with CP. Dev Med Child Neurol. 1999;41:766 –776.

Invited Commentary During walking at preferred speeds, young children with cerebral palsy (CP)—in comparison with children with typical development—show differences in timing of trunk and hip muscle activation, marked by excessive muscle activation during almost the entire stride cycle and with increased coactivation between the ipsilateral rectus abdominis and erector spinae muscle pair and the rectus femoris and semitendinosus muscle pair. This conclusion by Prosser and colleagues1 was based on surface electromyogphic recordings of 8 trunk, gluteal, and thigh muscles on both body sides. They hypothesize that the excessive muscle activation may create a functionally rigid trunk, limiting “the child’s ability to make fine adjustments to trunk position relative to the lower extremities and the environment and the therapist’s ability to grade muscle activity in response to external perturbations.” Similarly, the ability to control the body’s center of mass during walking will be hampered. Thus, the authors continue, the physical therapy July 2010

42 Woollacott MH, Burtner P, Jensen J, et al. Development of postural responses during standing in healthy children and children with spastic diplegia. Neurosci Biobehav Rev. 1998;22:583–589. 43 Nashner LM, Shumway-Cook A, Marin O. Stance posture control in select groups of children with cerebral palsy: deficits in sensory organization and muscular coordination. Exp Brain Res. 1983;49:393– 409. 44 Roerdink M, De Haart M, Daffertshofer A, et al. Dynamical structure of center-ofpressure trajectories in patients recovering from stroke. Exp Brain Res. 2006;174: 256 –269. 45 Hsue BJ, Miller F, Su FC. The dynamic balance of the children with cerebral palsy and typical developing during gait, part I: spatial relationship between COM and COP trajectories. Gait Posture. 2009;29: 465– 470. 46 Boyd RN, Morris ME, Graham HK. Management of upper limb dysfunction in children with cerebral palsy: a systematic review. Eur J Neurol. 2001;8(suppl 5):150 – 166.

47 Damiano DL, Alter KE, Chambers H. New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy. Phys Med Rehabil Clin North Am. 2009;20:469 – 491. 48 Abt JP, Smoliga JM, Brick MJ, et al. Relationship between cycling mechanics and core stability. J Strength Cond Res. 2007; 21:1300 –1304. 49 Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg. 2005;13:316 –325. 50 Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil. 2009;90:1185– 1195.

Robert C. Wagenaar

interventions should focus on the reduction of excessive trunk and hip muscle activation and the improvement of the coordination of trunk movements. Prosser and colleagues’ study of CP gait is unique in recognizing the importance of evaluating the impaired control of trunk and hip muscle activity during posture, gait, and upright movement in general. The authors emphasize that the literature on CP gait has addressed mainly the kinematics and biomechanics of the lower extremities, which is a general concern in the study of pathological gait.2 Another remarkable feature of Prosser and colleagues’ study is the inclusion of children with CP and children with TD with similar walking experience, ranging from 1 month to 5 years. According to the authors, the best evidence indicates that walking experience is a stronger predictor of walking and balance skill than age in early walkers. Walking experience was estimated by the difference between the child’s age

on the day of study and the age at onset of walking. The major concern with the outcomes and the conclusions by Prosser and colleagues is whether the excessive trunk and hip muscle activity observed in the children with CP during walking is the result of their neurological disorder or the low speed at which they prefer to walk. In addition, it is open to further investigation how the excessive trunk and hip muscle activity affects the coordination dynamics and biomechanics of the pelvic, thoracic, and trunk rotations. For example, Wagenaar and Beek3 demonstrated that systematically increasing walking speed from 0.25 to 1.50 m/s results in a change in the coordination of trunk rotation in the transversal plane from an in-phase relationship between pelvic and thoracic rotations (pelvis and thorax move in the same direction) in the lower speed range (0.25– 0.75 m/s) to an out-ofphase relationship (counter-rotation between pelvis and thorax) in the

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Muscle Activation Patterns During Walking in Children 37 Vorro J, Hobart D. Kinematic and myoelectric analysis of skill acquisition, I: 90-cm subject group. Arch Phys Med Rehabil. 1981;62:575–582. 38 Bjornson KF, Belza B, Kartin D, et al. Ambulatory physical activity performance in youth with cerebral palsy and youth who are developing typically. Phys Ther. 2007; 87:248 –257. 39 Ferdjallah M, Harris GF, Smith P, Wertsch JJ. Analysis of postural control synergies during quiet standing in healthy children and children with cerebral palsy. Clin Biomech (Bristol, Avon). 2002;17:203–210. 40 van der Heide JC, Begeer C, Fock JM, et al. Postural control during reaching in preterm children with cerebral palsy. Dev Med Child Neurol. 2004;46:253–266. 41 Hadders-Algra M, van der Fits IB, Stremmelaar EF, Touwen BC. Development of postural adjustments during reaching in infants with CP. Dev Med Child Neurol. 1999;41:766 –776.

Invited Commentary During walking at preferred speeds, young children with cerebral palsy (CP)—in comparison with children with typical development—show differences in timing of trunk and hip muscle activation, marked by excessive muscle activation during almost the entire stride cycle and with increased coactivation between the ipsilateral rectus abdominis and erector spinae muscle pair and the rectus femoris and semitendinosus muscle pair. This conclusion by Prosser and colleagues1 was based on surface electromyogphic recordings of 8 trunk, gluteal, and thigh muscles on both body sides. They hypothesize that the excessive muscle activation may create a functionally rigid trunk, limiting “the child’s ability to make fine adjustments to trunk position relative to the lower extremities and the environment and the therapist’s ability to grade muscle activity in response to external perturbations.” Similarly, the ability to control the body’s center of mass during walking will be hampered. Thus, the authors continue, the physical therapy July 2010

42 Woollacott MH, Burtner P, Jensen J, et al. Development of postural responses during standing in healthy children and children with spastic diplegia. Neurosci Biobehav Rev. 1998;22:583–589. 43 Nashner LM, Shumway-Cook A, Marin O. Stance posture control in select groups of children with cerebral palsy: deficits in sensory organization and muscular coordination. Exp Brain Res. 1983;49:393– 409. 44 Roerdink M, De Haart M, Daffertshofer A, et al. Dynamical structure of center-ofpressure trajectories in patients recovering from stroke. Exp Brain Res. 2006;174: 256 –269. 45 Hsue BJ, Miller F, Su FC. The dynamic balance of the children with cerebral palsy and typical developing during gait, part I: spatial relationship between COM and COP trajectories. Gait Posture. 2009;29: 465– 470. 46 Boyd RN, Morris ME, Graham HK. Management of upper limb dysfunction in children with cerebral palsy: a systematic review. Eur J Neurol. 2001;8(suppl 5):150 – 166.

47 Damiano DL, Alter KE, Chambers H. New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy. Phys Med Rehabil Clin North Am. 2009;20:469 – 491. 48 Abt JP, Smoliga JM, Brick MJ, et al. Relationship between cycling mechanics and core stability. J Strength Cond Res. 2007; 21:1300 –1304. 49 Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg. 2005;13:316 –325. 50 Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil. 2009;90:1185– 1195.

Robert C. Wagenaar

interventions should focus on the reduction of excessive trunk and hip muscle activation and the improvement of the coordination of trunk movements. Prosser and colleagues’ study of CP gait is unique in recognizing the importance of evaluating the impaired control of trunk and hip muscle activity during posture, gait, and upright movement in general. The authors emphasize that the literature on CP gait has addressed mainly the kinematics and biomechanics of the lower extremities, which is a general concern in the study of pathological gait.2 Another remarkable feature of Prosser and colleagues’ study is the inclusion of children with CP and children with TD with similar walking experience, ranging from 1 month to 5 years. According to the authors, the best evidence indicates that walking experience is a stronger predictor of walking and balance skill than age in early walkers. Walking experience was estimated by the difference between the child’s age

on the day of study and the age at onset of walking. The major concern with the outcomes and the conclusions by Prosser and colleagues is whether the excessive trunk and hip muscle activity observed in the children with CP during walking is the result of their neurological disorder or the low speed at which they prefer to walk. In addition, it is open to further investigation how the excessive trunk and hip muscle activity affects the coordination dynamics and biomechanics of the pelvic, thoracic, and trunk rotations. For example, Wagenaar and Beek3 demonstrated that systematically increasing walking speed from 0.25 to 1.50 m/s results in a change in the coordination of trunk rotation in the transversal plane from an in-phase relationship between pelvic and thoracic rotations (pelvis and thorax move in the same direction) in the lower speed range (0.25– 0.75 m/s) to an out-ofphase relationship (counter-rotation between pelvis and thorax) in the

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Muscle Activation Patterns During Walking in Children higher speed range (1.0 –1.5 m/s). That is, at lower walking speeds, there is no counter-rotation in the trunk that coincides with a limited contribution of the transverse pelvic rotation to the lengthening of the stride. However, from 1.0 m/s onward, there is a significant counter-rotation in the trunk as a result of the increased contribution of the transverse pelvic rotation to the lengthening of the stride (“pelvic step”). In their study of interlimb coordination during walking, Wagenaar and van Emmerik4 showed these differences in phase relationship between transverse pelvic and thoracic rotations are associated with different coordination patterns (frequency and phase relations) between arm and leg movements. Applying dimensionless analysis, Wagenaar and Beek3 were able to classify disorders in trunk and pelvic rotations in the transversal plane in individuals after a stroke. Although the participants in Wagenaar and Beek’s study were adults and Prosser and colleagues’ study included children with ages ranging from 1 to 9 years, these observations create an interesting perspective on the comparison of trunk and hip muscle activity between CP and TD gait in Prosser and colleagues’ study. Prosser and colleagues state that the majority of the children with CP are unable to walk at speeds similar to those of the children with TD and that children with TD have difficulty walking at a steady state at slow speeds. Therefore, they instructed the participants to walk at their preferred speeds. They report that the average normalized (or dimensionless) walking speed was 0.22 (SD⫽0.10) for the CP group and 0.42 (SD⫽0.06) for the TD group. In Wagenaar and Beek’s study,3 these normalized walking speeds are close to 998

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0.60 and 1.25 m/s, respectively, which suggests that Prosser and colleagues are comparing trunk and hip muscle activity patterns between the CP and TD groups associated with different trunk and interlimb coordination patterns. The authors indicate that although the walking experience between the CP and TD groups was similar, the TD group most likely had more walking practice, which supports the observed difference in normalized walking speed. In addition, the CP group was older than the TD group (mean [⫾SD] age: 63.1⫾23.2 months versus 39.7⫾ 19.5 months) and had a larger weight (mean [⫾SD] weight: 19.6⫾5.9 kg versus 15.1⫾3.9 kg). Less walking practice and larger weight may explain the differences in normalized walking speed and trunk and hip muscle activation patterns between the CP and TD groups. More importantly, the difference in normalized walking speed in itself may have caused a difference in trunk and hip muscle activation patterns independent of the neurological disorder. The same may be true for differences in normalized stride frequency and stride length.3 Therefore, it is important that the authors present the differences in walking speed, stride frequency, stride length, as well as trunk and hip rotations in the various planes, between the CP and TD groups. These data will provide a better understanding of the impact of the observed differences in trunk and hip muscle activation patterns. It also should be noted that the children with CP were allowed to walk with assistive devices, and only 3 children with CP walked without assistive devices. The usage of rolling walkers and bilateral and unilateral forearm crutches will dramatically influence trunk and hip muscle activation patterns.

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The excessive, nonreciprocal trunk and hip muscle activation during walking observed by Prosser and colleagues in children with CP compared with children with TD is consistent with the observed excessive muscle activation patterns in the lower extremities in children with CP. Ho and colleagues5 demonstrated that at comfortable walking speeds, children with CP have a smaller normalized stride length, with a slightly higher normalized stride frequency, than children with TD. These differences between children with CP and children with TD coincided with higher values in normalized stiffness estimated by an escapement-driven pendulum and spring system model, approaching the level of significance. It is important to note that in Ho and colleagues’ study, the median absolute and normalized walking speeds were 0.73 m/s and 0.31, respectively, for the children with CP and 1.10 m/s and 0.45, respectively, for the children with TD. These normalized walking speed values are close to the values observed in Prosser and colleagues’ study. After one treatment session applying functional electrical stimulation to the gastrocnemiussoleus muscle complex, Ho et al5 observed an increased normalized impulse without finding any immediate effects on stride length, stride frequency, and stiffness. This finding suggests that the gait of children with CP can be best modeled as a “bouncing ball,” reflecting the usage of the spring-like properties of the lower extremities. However, the gait in children with TD also benefits from the pendulum characteristics of the lower and upper extremities, which requires no counter-rotation between the pelvis and thorax at speeds lower than 1.0 m/s and a counter-rotation in the trunk for 1.0 m/s onward.4 From a dynamics systems perspective, it can be hypothesized that the difference in timing of trunk and hip muscle activity with July 2010

Muscle Activation Patterns During Walking in Children excessive coactivation patterns in CP gait is an adaptation in muscle dynamics to allow for small increases in stride length, stride frequency, and walking speed. From this perspective, it can be hypothesized that the application of functional electrical stimulation for a number of weeks in children with CP improves not only impulse, but also stiffness, stride length, stride frequency, and walking speed. A full understanding of changes in trunk and hip muscle activation patterns during walking in children with CP in comparison with children with TD requires using normalized walking speed as a reference and detailed understanding of the coordina-

Author Response We thank Wagenaar1 for his perspective on the influence of walking speed on muscle activation patterns and appreciate his contributions to the understanding of coordination dynamics during walking. We recognize that both trunk muscle activation patterns and kinematic trunk dynamics are important components of gait biomechanics and that each may influence the other. We emphasize, however, that neither can be inferred from the other at current levels of understanding. The results that Wagenaar cites on the speed thresholds for different phase relationships of the pelvis and thorax2 originate from data from 4 adults who were healthy. With a small adult sample, we hesitate to assume that those speed thresholds for trunk and interlimb coordination are similar in young children during the first few years of walking. Wagenaar also suggests that despite the 2 groups having equal months of

July 2010

tion dynamics and biomechanics of gait. Without these requirements, it is difficult to provide a valid comparison between CP and TD gait, allowing for a theoretical understanding of the observed changes in muscle dynamics in children with CP. Children with CP walk slower than children with TD, which may allow for the emergence of different trunk and interlimb coordination patterns and, therefore, different muscle activation patterns. R.C. Wagenaar, PhD, is Professor of Physical Therapy and Athletic Training, Director, Doctor of Science in Rehabilitation Sciences Program, and Director, Center for Neurorehabilitation, Sargent College of Health and Rehabilitation Sciences, Boston University, 635 Commonwealth Ave, Boston, MA

02215. Address all correspondence to Dr Wagenaar at: [email protected]. DOI: 10.2522/ptj.20090161.ic

References 1 Prosser LA, Lee SCK, VanSant AF, et al. Trunk and hip muscle activation patterns are different during walking in young children with and without cerebral palsy. Phys Ther. 2010;90:986 –997. 2 Wagenaar RC, van Emmerik REA. Dynamics of movement disorders. Hum Mov Sci. 1996:15:161–175. 3 Wagenaar RC, Beek WJ. Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech. 1992:25;1007–1015. 4 Wagenaar RC, van Emmerik REA. Resonant frequencies of arms and legs identify different walking patterns. J Biomech. 2000:33; 853– 861. 5 Ho CL, Holt KG, Saltzman E, Wagenaar RC. Functional electrical stimulation changes dynamic resources in children with spastic cerebral palsy. Phys Ther. 2006;86: 987–1000.

Laura A. Prosser, Samuel C.K. Lee, Ann F. VanSant, Richard T. Lauer

walking experience, the group with typical development (TD) likely had greater amounts of walking practice than the group with cerebral palsy (CP), which “supports the observed difference in normalized walking speed.”1 It might be extrapolated from this statement that children with CP simply need more practice to be able to walk faster. Clinicians, unfortunately, are well aware that this is not the case. In our study, there was no increase in normalized speed as a function of practice in either group, nor was there a difference in normalized speed with age after the first year of walking as reported in Sutherland and colleagues’ seminal work.3 Thus, we conclude that walking practice alone does not predict walking speed. In Wagenaar and colleagues’ previous work,4 axial stiffness of the trunk in children with TD increased with increasing walking speed; the finding of increased axial stiffness was

consistent with results of other studies cited in that article. There was, as the authors mention, “no attempt to differentiate the contribution of passive stiffness due to the elastic properties of connective tissues such as ligaments and active stiffness due to muscle contraction.”4(p754) Given these results, if children with CP exhibited walking characteristics of individuals with TD and if children with CP walk slower than those with TD, then it might be predicted that children with CP would exhibit less stiffness than individuals with TD. This scenario is counter to what we observed in children with CP in the present study.5 Rather, the slower walking individuals with CP demonstrated much greater co-contraction than their faster walking counterparts with TD. We believe our proposal that the differences in muscle activity observed between the groups with CP and TD are attributable to the brain injury

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Muscle Activation Patterns During Walking in Children excessive coactivation patterns in CP gait is an adaptation in muscle dynamics to allow for small increases in stride length, stride frequency, and walking speed. From this perspective, it can be hypothesized that the application of functional electrical stimulation for a number of weeks in children with CP improves not only impulse, but also stiffness, stride length, stride frequency, and walking speed. A full understanding of changes in trunk and hip muscle activation patterns during walking in children with CP in comparison with children with TD requires using normalized walking speed as a reference and detailed understanding of the coordina-

Author Response We thank Wagenaar1 for his perspective on the influence of walking speed on muscle activation patterns and appreciate his contributions to the understanding of coordination dynamics during walking. We recognize that both trunk muscle activation patterns and kinematic trunk dynamics are important components of gait biomechanics and that each may influence the other. We emphasize, however, that neither can be inferred from the other at current levels of understanding. The results that Wagenaar cites on the speed thresholds for different phase relationships of the pelvis and thorax2 originate from data from 4 adults who were healthy. With a small adult sample, we hesitate to assume that those speed thresholds for trunk and interlimb coordination are similar in young children during the first few years of walking. Wagenaar also suggests that despite the 2 groups having equal months of

July 2010

tion dynamics and biomechanics of gait. Without these requirements, it is difficult to provide a valid comparison between CP and TD gait, allowing for a theoretical understanding of the observed changes in muscle dynamics in children with CP. Children with CP walk slower than children with TD, which may allow for the emergence of different trunk and interlimb coordination patterns and, therefore, different muscle activation patterns. R.C. Wagenaar, PhD, is Professor of Physical Therapy and Athletic Training, Director, Doctor of Science in Rehabilitation Sciences Program, and Director, Center for Neurorehabilitation, Sargent College of Health and Rehabilitation Sciences, Boston University, 635 Commonwealth Ave, Boston, MA

02215. Address all correspondence to Dr Wagenaar at: [email protected]. DOI: 10.2522/ptj.20090161.ic

References 1 Prosser LA, Lee SCK, VanSant AF, et al. Trunk and hip muscle activation patterns are different during walking in young children with and without cerebral palsy. Phys Ther. 2010;90:986 –997. 2 Wagenaar RC, van Emmerik REA. Dynamics of movement disorders. Hum Mov Sci. 1996:15:161–175. 3 Wagenaar RC, Beek WJ. Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech. 1992:25;1007–1015. 4 Wagenaar RC, van Emmerik REA. Resonant frequencies of arms and legs identify different walking patterns. J Biomech. 2000:33; 853– 861. 5 Ho CL, Holt KG, Saltzman E, Wagenaar RC. Functional electrical stimulation changes dynamic resources in children with spastic cerebral palsy. Phys Ther. 2006;86: 987–1000.

Laura A. Prosser, Samuel C.K. Lee, Ann F. VanSant, Richard T. Lauer

walking experience, the group with typical development (TD) likely had greater amounts of walking practice than the group with cerebral palsy (CP), which “supports the observed difference in normalized walking speed.”1 It might be extrapolated from this statement that children with CP simply need more practice to be able to walk faster. Clinicians, unfortunately, are well aware that this is not the case. In our study, there was no increase in normalized speed as a function of practice in either group, nor was there a difference in normalized speed with age after the first year of walking as reported in Sutherland and colleagues’ seminal work.3 Thus, we conclude that walking practice alone does not predict walking speed. In Wagenaar and colleagues’ previous work,4 axial stiffness of the trunk in children with TD increased with increasing walking speed; the finding of increased axial stiffness was

consistent with results of other studies cited in that article. There was, as the authors mention, “no attempt to differentiate the contribution of passive stiffness due to the elastic properties of connective tissues such as ligaments and active stiffness due to muscle contraction.”4(p754) Given these results, if children with CP exhibited walking characteristics of individuals with TD and if children with CP walk slower than those with TD, then it might be predicted that children with CP would exhibit less stiffness than individuals with TD. This scenario is counter to what we observed in children with CP in the present study.5 Rather, the slower walking individuals with CP demonstrated much greater co-contraction than their faster walking counterparts with TD. We believe our proposal that the differences in muscle activity observed between the groups with CP and TD are attributable to the brain injury

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Muscle Activation Patterns During Walking in Children resulting in CP and not a result of slower walking is supported by the literature. As mentioned in our article, previous studies6,7 showed that for children with TD there were significant changes in electromyography (EMG) signal amplitude, with little effect on the timing of the muscle activation at the walking speeds demonstrated by our group with CP. Schwartz et al8 reported decreased EMG amplitude at slow and very slow speeds for all lower-extremity muscles studied in children with TD. Therefore, if our results were attributable to gait speed, activation time would be expected to be smaller in the group with CP as a result of reduced signal amplitude during slow walking (as amplitude decreases, activity during a smaller percentage of the gait cycle would be above the threshold). This scenario is again counter to the observations of the current study and further emphasizes the presence of excessive muscle activity in the group with CP. We make 2 final points regarding the influence of walking speed on EMG data in general. First, caution should be taken in extrapolating from studies that report differences in EMG patterns within individuals walking at varied speeds to data that are being compared between groups who walk at different speeds. To our knowledge, no one has compared muscle activity during self-selected and fixed speeds between specific patient and control groups in order to determine whether activation patterns during either self-selected or fixed speeds more closely approximate each other across specific diagnostic groups.

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Second, although we agree that walking speed can be a confounding factor in interpreting EMG data, we maintain that this depends on the study design. For example, if the research question is to investigate the effects of a lower-extremity orthosis on trunk and proximal muscle function during walking, we agree that walking speed is a confounding factor and postulate that a pretestposttest study design in which walking speed is controlled would be the most appropriate for the study. In the design of the present study, however, we did not investigate an intervention, nor did we explore the relationship of a particular biomechanical measure to changes in walking speed. We explored what occurs in the development of walking in children with CP versus those with TD using a cross-sectional design. Thus, in our case, we feel that it is more important for walking speed to be a dependent variable measured across groups. Walking speed conceived as an independent variable controlled across groups addresses a decidedly different question. This discussion highlights a difficult problem, as well as several gaps, in our existing knowledge of gait biomechanics and the development of impaired walking in specific patient groups. As clinicians and researchers, we need to explore all of the avenues mentioned in Wagenaar’s commentary to reduce the current limitations of our knowledge. Investigating trunk kinematics and coordination dynamics in early walkers with and without CP would be a valuable endeavor and could aid in the development of treatment programs.

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We appreciate this opportunity to share our work and to discuss a topic relevant to several areas in physical therapy, including gait biomechanics, research methods, pediatrics, and neurology. We hope this discussion contributes to the understanding of the choices with which researchers struggle and the limitations to interpretation of which clinicians should be aware. We look forward to further investigation of the influence of walking speed on muscle activation patterns, particularly across various diagnostic groups. DOI: 10.2522/ptj.20090161.ar

References 1 Wagenaar RC. Invited commentary on “Trunk and hip muscle activation patterns are different during walking in young children with and without cerebral palsy.” Phys Ther. 2010;90:997–999. 2 Wagenaar RC, Beek WJ. Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech. 1992:25;1007–1015. 3 Sutherland D, Olshen R, Biden E, Wyatt M. The Development of Mature Walking. London, United Kingdom: Cambridge University Press; 1988. 4 Kubo M, Holt KG, Saltzman E, Wagenaar RC. Changes in axial stiffness of the trunk as a function of walking speed. J Biomech. 2006;39:750 –757. 5 Prosser LA, Lee SCK, VanSant AF, et al. Trunk and hip muscle activation patterns are different during walking in young children with and without cerebral palsy. Phys Ther. 2010;90:986 –997. 6 Den Otter AR, Geurts AC, Mulder T, Duysens J. Speed related changes in muscle activity from normal to very slow walking speeds. Gait Posture. 2004;19:270 –278. 7 van Hedel HJ, Tomatis L, Muller R. Modulation of leg muscle activity and gait kinematics by walking speed and bodyweight unloading. Gait Posture. 2006;24:35– 45. 8 Schwartz MH, Rozumalski A, Trost JP. The effect of walking speed on the gait of typically developing children. J Biomech. 2008; 41:1639 –1650.

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Research Report Physical Activity Behavior of People With Multiple Sclerosis: Understanding How They Can Become More Physically Active Heleen Beckerman, Vincent de Groot, Maarten A. Scholten, Jiska C.E. Kempen, Gustaaf J. Lankhorst

Background. People with multiple sclerosis (MS) are less physically active than those without the disease. Understanding the modifiable factors that are related to physical inactivity is important for developing effective physical activity programs. Objective. The objectives of this study were to determine levels of physical activity and to determine factors related to the physical activity behavior of adults with MS by use of the Physical Activity for People With a Disability (PAD) model. The PAD model combines the International Classification of Functioning, Disability and Health framework of disability and theoretical models of physical activity behavior.

Design. This investigation was a cross-sectional study. Methods. The study participants were 106 people who had MS and who, since their definite diagnosis, had been participating in a prospective cohort study. Physical activity was assessed with the Short Questionnaire to Assess Health-Enhancing Physical Activity. The independent roles of disease characteristics and demographic, cognitive-behavioral, and environmental factors were determined using questionnaires for which reliability and validity have been established.

Results. The median total level of physical activity of participants with MS (mean age⫽42.8 years, median Expanded Disability Status Scale score⫽3, disease duration⫽6 years) was 10.68 metabolic equivalents ⫻ h/d (interquartile range⫽3.69 – 16.57). On average, participants spent 30 h/wk on activities with metabolic equivalents of 2 or more (interquartile range⫽10.7– 45.0 h/wk). The regression models predicting physical activity behavior on the basis of demographic (29.4%) and disease-related (28.3%) variables explained more variance than the models based on cognitive-behavioral (12.0%) and environmental (9.1%) variables. Combining significant variables yielded a final regression model that explained 37.2% of the variance in physical activity. Significant determinants were disease severity, a disability pension, and having children to care for.

Limitations. Changes in physical activity behavior were not measured. Conclusions. Participants with MS were less active if their disease was more severe, if they received a disability pension, or if they had children to care for. The PAD model was helpful in understanding the physical activity behavior of participants with MS.

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H. Beckerman, PT, PhD, is Senior Researcher, Department of Rehabilitation Medicine, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, the Netherlands. Address all correspondence to Dr Beckerman at: [email protected]. V. de Groot, MD, PhD, is Rehabilitation Physician and Senior Researcher, Department of Rehabilitation Medicine, VU University Medical Center, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center. M.A. Scholten, MD, was a medical student, Faculty of Medicine, VU University Medical Center, at the time of the study. J.C.E. Kempen, PT, MSc, is a PhD candidate, Department of Rehabilitation Medicine, VU University Medical Center, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center. G.J. Lankhorst, MD, PhD, is Rehabilitation Physician, Professor, and Head of the Department, Department of Rehabilitation Medicine, VU University Medical Center, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center. [Beckerman H, de Groot V, Scholten MA, et al. Physical activity behavior of people with multiple sclerosis: understanding how they can become more physically active. Phys Ther. 2010;90:1001–1013.] © 2010 American Physical Therapy Association

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Post a Rapid Response to this article at: ptjournal.apta.org Physical Therapy f

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ultiple sclerosis (MS) is a chronic, disabling disease of the central nervous system that is mainly diagnosed between the ages of 20 and 40 years; its incidence is approximately 6 in 100,000 people. In addition to the neurological symptoms, more than 70% of patients with MS experience fatigue, and 50% to 60% report fatigue as one of their worst symptoms.1 Fatigue can be so persistent that it leads to limitations in social functioning, even in patients with minor neurological deficits. A recent cohort study showed that early in the course of MS, social functioning is seriously affected, whereas for the majority of patients with MS, neurological deficits are minor and physical functioning is minimally affected.2 Fatigue and personality factors were reported to be the most important determinants of this decrease in social functioning.3,4 The causes of fatigue in people with MS are largely unknown, but one of the assumed causes is reduced aerobic capacity.4 – 6 Petajan et al7 hypothesized that fatigue leads to a decrease in physical activity, which leads to impaired fitness; the latter, in turn, leads to more fatigue. This scenario may be an important reason for encouraging physical activity programs in people with MS. Obviously, other important reasons for regular physical activity are the expected long-term positive effects on health and the prevention of comorbid health problems. In the general

Available With This Article at ptjournal.apta.org • The Bottom Line Podcast • Audio Abstracts Podcast This article was published ahead of print on May 27, 2010, at ptjournal.apta.org.

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population, the benefits and protective effects of a physically active lifestyle are well known.8,9 An active lifestyle is accompanied by various fitness and health benefits: an increased life expectancy free of disability, lower risk of chronic diseases (eg, coronary artery disease, stroke, diabetes mellitus type II, colon cancer), and unhealthful weight gain, and an increase in the rate of recovery from disability in people who are 50 to 80 years of age.10 –12 Several clinical trials have assessed the therapeutic effects of exercise in people with MS.13–15 There is strong evidence in favor of exercise therapy compared with no exercise therapy, but there is no evidence that specific exercise programs are superior to others in improving activities and social functioning. The limited contrast among these exercise programs may be an important reason why no differences in effectiveness have been reported. However, from studies of people with disabilities, coronary artery disease, and chronic obstructive pulmonary disorders, there is evidence that high-intensity aerobic interval training is more effective than moderately intense aerobic endurance training.16 –18 Although there is still much to be learned about the extent to which patients with MS can be physically active and about their physiological responses to training, intensive exercise programs do not influence the progression of MS or cause exacerbations.13,14 Physical inactivity is a major public health problem, particularly in people with disabilities.19 In a metaanalysis of 13 studies of 2,360 patients with MS, the cumulative evidence suggested that patients with MS are less physically active than people without disease.20 Little research has focused on physical activity behavior and understanding physical activity levels in patients with MS. Understanding the modifi-

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able factors that are related to physical inactivity is important for developing effective physical activity promotion programs for patients with MS. The aims of this study were to determine levels of physical activity and to determine factors related to the physical activity behavior of adults with MS. We used the Physical Activity for People With a Disability (PAD) model as a theoretical framework.21 The PAD model combines the framework of functioning from the International Classification of Functioning, Disability and Health (ICF) with several theoretical models of determinants of physical activity behavior (eg, the social cognitive theory, the transtheoretical model, the health belief model, the protection motivation theory, and the theory of planned behavior).21–23 All of these theories postulate that effective interventions that improve physical activity behavior are due to changes in intermediate variables, such as cognition, self-efficacy, knowledge, skills, current behavior, social support, balance between “pros” and “cons” in decision making, perceived barriers and benefits, and enjoyment. The ICF framework describes the multidimensional aspects of functioning in people with a disability in terms of body functions and structures, activities, and participation.21–23

Method Participants and Design This study was part of a long-term prospective follow-up study of functional prognosis in an inception cohort of 156 patients with a definite diagnosis of MS. From 1998 to 2000, all consecutive adult patients who had a recent diagnosis (⬍6 months earlier) of MS and who were visiting the outpatient neurology clinics of 5 participating hospitals were invited to participate in the study. Patients with comorbid neurological disorders or systemic or malignant neoJuly 2010

Physical Activity in Multiple Sclerosis plastic diseases at baseline were excluded. Full details of the design of the longitudinal study have been reported elsewhere.2 For the additional study of physical activity behavior, 124 patients who had recently completed 6-year follow-up measurements were invited to complete a mailed questionnaire. The results of the questionnaire were cross-sectionally combined with the scores at the 6-year follow-up after the diagnosis of MS. All patients gave written informed consent prior to participation in the study. Measurement Instruments Physical activity. Physical activity can be defined as a behavior that involves all large-muscle movements for various purposes throughout the day. Metabolic equivalents (METs) are commonly used to express the intensity of physical activities.24 The MET is the ratio of the working metabolic rate to the resting metabolic rate. One MET is defined as the energy cost of sitting quietly and is equivalent to a caloric consumption of 1 kcal/kg/h. For adults (up to the age of 55 years), activities with a MET ranging from 2 to less than 4, ranging from 4 to less than 6.5, and 6.5 or greater are classified as light, moderate, and vigorously intense, respectively. For older adults (more than 55 years of age), activities with a MET ranging from 2 to less than 3, ranging from 3 to less than 5, and 5 or greater are classified as light, moderate, and vigorously intense, respectively.8,9 The level of physical activity was assessed with the Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH).25 The SQUASH is a self-report questionnaire that asks participants to recall their physical activity during an average week in the preceding month.25 The SQUASH contains questions regardJuly 2010

ing work-related activities, leisuretime activities, household activities, and means of transportation. Activities with a MET of less than 2 are not included in the SQUASH. Activity scores (MET ⫻ min/wk) were calculated with the following formula: frequency (d/wk) ⫻ duration (min/ d) ⫻ physical intensity (different MET intensity scores). The total activity score was calculated as the sum of the activity scores for separate questions. A theoretical maximum activity score has not been established.25,26 Potential determinants of physical activity. Many personal and environmental factors may influence physical activity behavior.11,21,22 Personal factors include demographic factors; disease-related factors; and cognitive and behavioral factors, such as knowledge of the effects of physical activity on health, attitude toward physical activity, selfefficacy, perceived benefits and barriers, motivation to adhere, and past physical activity behavior. Environmental factors include the social influence of family members and

friends, membership in a patient organization, normative beliefs of other people, and environmental barriers. All of these factors were determined with existing reliable and valid measurement scales and questionnaires that have been used in other physical activity studies.27–39 As independent variables for demographic characteristics we used age, gender, level of education (low, intermediate, or high), a disability pension (none, partial, or full), income (low, medium, high, or unknown), living arrangement (living alone or living with others), and having children to care for (yes or no). As disease-related factors we used type of MS onset (relapsing-remitting or non–relapsing-remitting); scores on the Expanded Disability Status Scale (EDSS), the Fatigue Severity Scale (FSS), the Center for Epidemiologic Studies Depression (CES-D) Scale, and the Cumulative Illness Rating Scale (CIRS); and the EuroQol 5-domain index (EQ-5D) utility score.27–32 With the exception of the EQ-5D, these disease-related factors

The Bottom Line What do we already know about this topic? People with multiple sclerosis are less physically active than those without the disease. Modifiable factors that are related to physical inactivity are important for developing effective physical activity programs.

What new information does this study offer? Three modifiable factors were identified: disease severity, receiving a disability pension, and having children to care for.

If you’re a patient, what might these findings mean for you? Patients should try to change their personal circumstances in order to stay physically active, such as finding effective ways to keep their job and continue to perform work-related activities, slowing down the disease progression, and finding support to care for their children.

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Physical Activity in Multiple Sclerosis are at the ICF level of body functions and structures.22 The EDSS assesses 7 neurological systems (visual/optical, brain stem, pyramidal, cerebellar, bowel/bladder, mental, and other) and provides information about walking ability, use of walking aids, and ability to perform self-care activities. Scores on the EDSS range from 0 to 10.27 Lower scores (0 –3) are calculated with a scoring paradigm based on the scores obtained from the neurological systems, intermediate scores (3.5– 6) are predominantly based on walking ability, and higher scores (6.5–10) are mainly based on the inability to perform self-care activities. The FSS measures an individual’s perceived level of fatigue in a variety of situations. Scores on the FSS range from 0 (lowest possible fatigue score) to 7 (highest possible fatigue score), with valid cutoff values of less than 4 indicating no fatigue and of 4 or greater indicating fatigue.28 The CES-D Scale is a 20-item list that classifies people as having no depression (scores of 0 –15) or having depressive symptoms (scores of 16 – 60).29,30 Comorbidity in addition to MS was measured with the CIRS, which is a short, physician-rated, comprehensive, and reliable instrument that can be used to assess the burden of chronic medical illness.31 The scale consists of 13 relatively independent categories grouped under body systems. Severity is rated on a 5-point scale, ranging from “none” to “extremely severe.” In the present study, we dichotomized the scores into 0 (no comorbidity) and greater than or equal to 1 (comorbidity). The EQ-5D, developed by the EuroQoL Group, measures perceived health outcomes in 5 domains: mobility, self-care, usual activities, pain 1004

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and discomfort, and anxiety and depression.32 Each domain is scored in 3 categories: no problems, some problems, and serious problems. An overall EQ-5D utility score then is calculated by subtracting from 1 a weighted value for each category. In the present study, we used the Dutch tariff to calculate the EQ-5D utility score.33 Thus, an individual who has no perceived problems in any domain would have an EQ-5D utility score of 1, indicating a state of perfect health. Death results in a utility score of 0. Among cognitive and behavioral factors, self-efficacy was assessed with the 12-item Self-Efficacy for Exercise Behavior Scale, which has 2 subscales: making time and resisting relapse.34 Participants with MS were asked to indicate how confident they were that they could be physically active in a variety of situations, such as “making time for my physical activity program.” Attitude toward physical activity is what people think and express about a physically active lifestyle for themselves. We assessed attitude with the Physical Activity Enjoyment Scale, which consists of 18 statements (11 positive and 7 negative).35 After rescaling of the negative statements, possible scores on the Physical Activity Enjoyment Scale range from 18 to 90. Perceived benefits of a physically active lifestyle were assessed with a 14-item scale on which participants with MS could rate their agreement with positive statements about the possible effects of regular physical activity (eg, “If I participate in regular physical activity, I will feel less stressed.”).36 Personal barriers for physical activity were measured with a 17-item questionnaire on which participants could indicate how often personal

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barriers might reduce their ability to engage in physical activity.36 The 5-item Exercise Stage of Change Questionnaire was used to assess each participant’s stage of change for regular moderate or vigorous physical activity.37 Five stages were distinguished: precontemplation, contemplation, preparation, action, and maintenance.37 The stage of change can actually be seen as a combination of physical activity status and attitude toward physical activity. The motivation to adhere to the normative expectations (beliefs) of family members and friends was measured with 5 items. Ten questions with “yes” or “no” answers were used to assess the participant’s knowledge of the effects of physical activity on health.38 The past behavior of participants was assessed with 1 question regarding at least 6 months of regular physical activity in the past (answered with “yes” or “no”). Among environmental factors, social influence is what other people think about a physically active lifestyle for the participant. Social support for physical activity was measured separately for family members and friends with the Support for Exercise Habits Scales developed by Sallis et al.39 The participants rated how often (from 1 [never] to 5 [very often]) family members and friends supported them in 13 situations (eg, “. . . performed physical activities with me”). The normative expectations (beliefs) of family members and friends were measured with 5 items. As described earlier, we also assessed the motivation of participants to adhere to these referent norms. Environmental barriers to physical activity were measured with a 14July 2010

Physical Activity in Multiple Sclerosis item questionnaire on which participants could indicate how often certain barriers might reduce their ability to engage in physical activity.36 Membership in a patient organization also was included in the analysis. Data Analysis Most of the instruments that are used to measure potential cognitivebehavioral and environmental determinants consist of 5-point Likert scales. To make it possible for us to estimate a meaningful total score for each measure, 75% of the items had to be answered. Overall, higher scores indicated higher self-efficacy, more perceived benefits, more perceived barriers, more social support, and so forth. Because several theoretical models are combined in the PAD model, including many interrelated determinants, we used a stepwise analysis approach to explain and understand the variance in the total physical activity behavior of our participants, as measured with the SQUASH (in MET ⫻ h/wk). After the univariate analyses, significant variables (with a liberal P value of ⱕ.20) were retained and tested in 4 subsequent regression analyses. Collinearity between the remaining variables was checked but did not result in the exclusion of variables for the next step. For each of the 4 sets of determinants, that is, demographic, disease-related, cognitive-behavioral, and environmental variables, we constructed a multivariate regression model; from each of these 4 regression models, the significant variables (Pⱕ.05) were further analyzed in the final regression model. All statistical analyses were performed with SPSS version 15.0.*

* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Table 1. Demographic and Disease-Related Characteristics of 106 Participants with Multiple Sclerosisa No. of Participants

% of Participants

20–35

31

29.2

36–50

52

49.1

51–65

23

21.7

Male

40

37.7

Female

66

62.3

Low

24

22.9

Intermediate

42

40.0

High

39

37.1

No

44

42.7

Yes, partial

22

21.4

Yes, full

37

35.9

Low (⬍1,500 Euros)

56

52.8

Medium (1,500–2,500 Euros)

25

23.6

Characteristic Demographic Age (y)

Gender

Level of educationb

Disability pensionb

Income

High (⬎2,500 Euros)

6

5.7

19

17.9

Living alone

20

19.2

Living with others

84

80.8

No

52

50.0

Yes

52

50.0

Relapsing-remitting

88

83.0

Non–relapsing-remitting

18

17.0

0–3

56

53.3

3.5–6

40

38.1

6.5–10

9

8.6

Unknown Living arrangementb

Children to care forb

Disease related Type of onset

EDSS

b

(Continued)

Role of the Funding Source This study was carried out as part of the FUPRO-MS II project, “LongTerm Prognosis of Functional Outcome in Neurological Disorders,” and was supported by the Nether-

lands Organization for Health Research and Development (ZonMw Project: 1435.0020). The funding agency had no influence on the design, conduct, or reporting of the study.

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Physical Activity in Multiple Sclerosis Table 1. Continued No. of Participants

% of Participants

No fatigue (⬍4)

21

20.2

Fatigue (ⱖ4)

83

79.8

No depression (⬍16)

77

74.8

Depressive symptoms (ⱖ16)

26

25.2

No comorbidity (0)

75

71.4

Comorbidity (ⱖ1)

30

28.6

Characteristic FSSb

CES-D Scaleb

CIRS

b

a

The EuroQol 5-domain index scores were as follows: median⫽0.78, 25th–75th percentiles⫽0.69 – 0.86. EDSS⫽Expanded Disability Status Scale, FSS⫽Fatigue Severity Scale, CES-D⫽Center for Epidemiologic Studies Depression, CIRS⫽Cumulative Illness Rating Scale. b Because of missing values, the total number does not equal 106.

Results Participant Characteristics Of the 124 participants with MS who were invited to participate, 106 (86%) completed the questionnaire on physical activity behavior. The main demographic and diseaserelated characteristics of these participants are summarized in Table 1. The 40 men (38%) and 66 women (62%) had a mean age of 42.7 years (SD⫽9.6 years), and more than half of the participants received a partial or full disability pension. Eightyeight participants had a relapsingremitting type of MS onset, and 18 had a non–relapsing-remitting type of MS onset. The median EDSS score was 3.0 (interquartile range⫽2.0 – 4.0), although 9 participants had an EDSS score of 6.5 or higher. All participants were living independently (ie, were not institutionalized). The majority of the participants (⬃80%) experienced fatigue (FSS score of ⱖ4), and about 25% had depressive symptoms, according to the CES-D Scale. As determined from the CIRS, about 29% of the participants had 1 or more comorbid diseases. The median EQ-5D score was 0.78 (interquartile range⫽0.69 – 0.87).

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Physical Activity The total activity score and domain scores on the SQUASH are shown in Table 2. The median total activity score was 10.68 MET ⫻ h/d (interquartile range⫽3.69 –16.57), with a minimum of 0 for 6 participants and a maximum of 35.86 for 1 highly active participant. The median total time spent on physical activities (METⱖ2) was 1,815 minutes, or approximately 30 h/wk (interquartile range⫽640 –2,700 minutes). Most of this time was spent on activities with a light intensity (MET⫽2– 4), such as light household activities. Only 16.5% of the participants performed activities with a vigorous intensity (Tab. 2). Most of the participants reported that they performed some household activities and leisure-time activities, such as walking, cycling, gardening, or odd jobs. The SQUASH results showed that about 42% of the participants had no work-related physical activities (MET ⫻ min/wk⫽0). Walking or cycling to and from work or school applied to 35% of the participants.

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Fifty-five participants engaged in 1 or more sports activities each week (1 sport, n⫽44; 2 sports, n⫽10; 4 sports, n⫽1), of which fitness, swimming, and gymnastics were the most popular. On average, 30 min/wk (interquartile range⫽0 –105 min/wk) were spent on sports activities by the total group (Tab. 2). According to international guidelines for regular physical activity, 64% (68/106) of the participants in our study were insufficiently physically active; that is, they were not engaged in moderately intense physical activities (METⱖ4) for at least 30 minutes on 5 days per week or vigorously intense aerobic activities (METⱖ6.5) for a minimum of 20 minutes on 3 days per week.8 Determinants of Physical Activity The demographic and diseaserelated characteristics of the participants are shown in Table 1. Table 3 shows their cognitive-behavioral and environmental characteristics. With respect to the stage of change, 16 participants (⬃15%) were in the precontemplation stage (ie, they were physically inactive people who did not intend to become active in the next 6 months), 9 (⬃8.%) were in the contemplation stage, and 14 (⬃13%) were in the preparation stage (currently but not regularly active). On the other hand, 49 participants were regularly physically active. However, because of misunderstanding the instructions or missing values, the stage of change of 18 participants was unknown. On the physical activity knowledge test, about 22% of the participants scored all 10 items correctly. They perceived more personal barriers than environmental barriers, and the most important items were lack of energy, fatigue, activity that was too heavy, poor health, no selfdiscipline, and social constraints or obligations. With respect to the benJuly 2010

Physical Activity in Multiple Sclerosis Table 2. Level of Physical Activity in Participants With Multiple Sclerosisa

P25–P75

No. (%) of Participants With No Activitiesb

0

0–60

0

0–150

67 (65.0)

Walking

0

0–0

0

0–0

88 (85.4)

Cycling

0

0–6

0

0–30

77 (74.8)

Min/wk Physical Activity, METⴛmin/wk Commuting to and from work or school

Activities at work or school Light Intense Household activities Light Intense Leisure-time activitiesc

Median

Activity Score

P25–P75

Median

420

0–1,440

900

0–3,600

43 (41.7)

180

0–1,200

360

0–2,400

48 (46.6)

0

0–0

480

230–1,050

450

210–840

0

0–60

0

0–0

86 (83.5)

1,260

480–2,280

900

420–1,680

15 (14.6)

0–300

61 (59.2)

0

15 (14.6)

130

20–360

420

80–1,200

25 (24.3)

Walking

20

0–120

30

0–240

50 (48.5)

Cycling

0

0–75

0

0–420

53 (51.5)

Gardening

0

0–30

0

0–150

67 (65.0)

0

0–15

0

0–16

76 (73.8)

30

0–105

0–540

49 (47.6)

Odd jobs Sports activities Total activities

120

1,815

640–2,700

4,486

1,550–6,960

6 (5.8)

1,260

510–2,310

2,520

960–4,620

9 (8.7)

750

150–1,620

23 (22.3)

All activities together, by intensity Light (MET⫽2–4) Moderate (MET⫽4–6.5) Vigorous (METⱖ6.5)

150 0

30–320 0–0

0

0–0

86 (83.5)

a

As measured with the Short Questionnaire to Assess Health-Enhancing Physical Activity. MET⫽metabolic equivalent, P25⫽25th percentile, P75⫽75th percentile. b Because of missing values, the data are based on 103 participants. c Leisure-time activities other than sports activities.

efits of regular physical activity, they were less convinced. The 3 benefits that received the highest scores were improved fitness, larger muscles, and increased muscle strength. Participants with positive intentions and at higher stages of change identified more benefits of physical activity and experienced fewer personal and environmental barriers. At the time of the interview, about 33% of the participants indicated that they intended to be more physically active in the next 6 months, about 31% were in doubt, and about 36% had no intention of increasing their level of activity. Fifty-nine percent of the participants expected that they would need an MS-specific exercise program in the near future. July 2010

Understanding Physical Activity Behavior: Stepwise Analyses Table 4 shows which variables remained for inclusion in the multivariate regression analysis after the univariate analyses. Three demographic variables (age, disability pension, and having children to care for) were significantly related to less physical activity and explained 29.4% of the variance in the SQUASH scores (Tab. 4). In the second model, a higher EDSS score, that is, more severe MS, and fatigue (FSS score of ⱖ4) resulted in significantly less physical activity. These 2 diseaserelated determinants explained 28.3% of the variance. With respect to the long list of cognitive and behavioral determinants, only 2 determinants were actually significant and

explained 12% of the variance in physical activity. Participants who experienced more personal barriers were less active; on the other hand, participants who were less motivated or less willing to adhere to the normative expectations of their family members and friends (ie, were better able to resist social pressure) were more active. None of the other cognitive or behavioral factors were associated with physical activity. Less variance was explained by the environmental variables (9.1%). Remarkably, participants who were members of a patient organization (60% of the study population) were less physically active than those who were not members.

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Physical Activity in Multiple Sclerosis Table 3. Cognitive-Behavioral and Environmental Characteristics of 106 Participants With Multiple Sclerosisa No. of Participants

% of Participants

16

15.1

9

8.5

14

13.2

5

4.7

Maintenance

44

41.5

No classification

18

17.0

Yes

71

74.7

No

24

25.3

Yes

33

32.7

Doubtful

31

30.7

No

37

36.6

Characteristic

Median

P25–P75

19.5

16–24.75

Cognitive-behavioral Exercise stage of change (n⫽106) Precontemplation Contemplation Preparation Action

Regularly active in the past (n⫽95)

Intention to perform more sports activities in the next 6 mo (n⫽101)

Knowledge of physical activity (n⫽101) All items correct

22

21.8

One or more items not correct

79

78.2

Self-Efficacy for Exercise Behavior Scale Making time for exercise (range of scores⫽5–30) (n⫽100)

20

16–24

Physical Activity Enjoyment Scale (range of scores⫽18–90) (n⫽97)

Resisting relapse (range of scores⫽5–30) (n⫽101)

71

62.0–76.5

Perceived benefits (range of scores⫽14–70) (n⫽99)

53

47.0–56.0

Personal barriers (range of scores⫽17–85) (n⫽102)

36

28.9–42.25

Motivation to adhere (range of scores⫽1–5) (n⫽96)

b

2.67

0.86

Environmental Support for Exercise Habits Scales Family members (range of scores⫽13–65) (n⫽98)

27

20.0–33.25

Friends (range of scores⫽13–65) (n⫽99)

21

15–29

Normative beliefs (range of scores⫽1–5) (n⫽95)b

2.45

Environmental barriers (range of scores⫽14–70) (n⫽101)

22

1.28 18–27

Membership in a patient organization (n⫽104)

a b

No

41

39.4

Yes

63

60.6

P25⫽25th percentile, P75⫽75th percentile. Reported as mean and standard deviation rather than median and P25–P75.

In the final regression model (Tab. 4), including the significant variables from the previous 4 models, age, fatigue, and all initially significant cognitive-behavioral and environmental variables were no 1008

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longer significantly related to physical activity. The most important variables explaining current physical activity behavior in participants with MS were disease severity, reliance on a full disability pension, and having

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children to care for. Participants were less active if their disease was more severe, if they received a disability pension, or if they had children to care for. The final model ac-

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Physical Activity in Multiple Sclerosis Table 4. Multivariate Regression Analysis of Physical Activity in Participants With Multiple Sclerosisa Final Modelb

Four Separate Models Regression Models and Determinants

Standardized ␤

B

95% Confidence Interval

⫺.261

⫺1.591

⫺2.628, ⫺0.554

Demographic Age

Adjusted R2

Standardized ␤

B

95% Confidence Interval

0.294

Disability pensionc No Yes, part time

⫺.231

⫺33.138

⫺59.778, ⫺6.588

⫺.140

⫺19.197

⫺44.331, 5.936

Yes, full time

⫺.483

⫺58.860

⫺81.021, ⫺36.699

⫺.341

⫺39.453

⫺61.041, ⫺17.865

⫺.258

⫺30.179

⫺50.286, ⫺10.072

⫺.248

⫺27.333

⫺46.195, ⫺8.470

⫺.416

⫺14.728

⫺20.877, ⫺8.578

Children to care for, yesc Disease related

0.283

EDSS

⫺.431

⫺15.473

⫺21.913, ⫺9.033

FSS, fatigue, yesc

⫺.223

⫺33.368

⫺60.240, ⫺6.496

⫺.308

⫺1.840

⫺3.108, ⫺0.573

.248

15.437

2.213, 28.860

Cognitive-behavioral Personal barriers Motivation to adhere

0.120

Environmental Membership in a patient organization, yesc Normative beliefs

0.091 ⫺.250

⫺27.475

⫺49.920, ⫺5.029

.201

8.861

⫺0.155, 17.878

a

Demographic, disease-related, cognitive-behavioral, and environmental variables were combined in the analysis. The dependent variable was the score on the Short Questionnaire to Assess Health-Enhancing Physical Activity, calculated as metabolic equivalents ⫻ hours per week. EDSS⫽Expanded Disability Status Scale, FSS⫽Fatigue Severity Scale. b The adjusted R2 of the final model was .372. c The “No” category was used as a reference.

counted for 37.2% of the variance in the total level of physical activity.

Discussion Our results show that physical activity behavior in people with MS is significantly explained by 3 independent factors: disease severity measured with the EDSS, receiving a disability pension, and having children to care for. Cognitive-behavioral and environmental factors play less important roles in the explanation of physical activity behavior. Therefore, severity of MS, receiving a disability pension, and having children to care for should be investigated further to guide the development of interventions to promote physical activity in people with MS. In this respect, the disability pension deserves special attention. AccordJuly 2010

ing to the Dutch Work and Income Act, after being on a sick list for 104 weeks, workers can claim a disability pension to compensate for part of the income that they have lost due to disability. In the present study, about 21% of the participants received a partial disability pension and about 36% received a full disability pension. Recently, however, various governments have changed their policies, increasingly promoting the prevention of work disability and facilitating work force participation. People with disabilities are being encouraged to continue working. Work contributes to personal identity and status, financial benefits, and improved quality of life, but longterm sickness absence and disability retirement have serious negative consequences for employees with MS, their employers, and society in

general.40 – 44 Physical therapists, especially those working in occupational health, ergonomics, and vocational rehabilitation, will be challenged to find effective ways to successfully help people with MS keep their jobs and continue to perform work-related physical activities.40 – 43 Furthermore, extended practice hours could be offered to allow people to have access to physical therapists before or after work. With respect to the significance of the EDSS results, low EDSS scores mainly indicate mild disease symptoms, intermediate EDSS scores (3.5– 6) predominantly indicate limitations in walking, and high EDSS scores (6.5–10) mainly indicate an inability to perform self-care activities. In people with intermediate EDSS scores, limitations in mobility

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Physical Activity in Multiple Sclerosis may be a further barrier to physical activity and participation in non–MSspecific exercise programs. Motl et al45 showed that for a group of 133 patients with MS and a mean selfreported EDSS score of 5.5, walking difficulty was a mediating variable between symptoms and physical activity; they suggested that interventions to promote physical activity might need to include adaptive activities that do not require walking ability. In this respect, the expertise of physical therapists is highly valued. Furthermore, it is important to effectively prevent further progression of the disease and to delay decreases in EDSS scores to levels at which even self-care activities are compromised. Prakash et al46 recently hypothesized that lifestyle factors, such as physical activities, may have neuroprotective effects in patients with MS. Further research is needed to justify this interesting hypothesis. Having children to care for, adjusted for disease severity and receiving a disability pension, was also negatively correlated with the total level of physical activity, including household activities. Moreover, social constraints and obligations were frequently mentioned as personal barriers. Family support or support from others in baby-sitting; child care offered by fitness centers, sports societies, or physical therapist practices; and time-management strategies may provide some solutions to enable patients with MS to become more physically active and reduce the competing demands of child care. Fatigue, type of MS onset (relapsing or nonrelapsing), depressive symptoms, self-efficacy, perceived barriers, and social support from family members and friends, among other factors, were unrelated to the total level of physical activity. These results are in agreement with those of Motl et al,45 who found that pain, 1010

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depression (CES-D Scale), and fatigue (FSS) were not correlated or were only slightly correlated with selfreported physical activity. However, in a large survey study of 2,995 veterans who had MS (86.5% men) and who were, on average, 12 years older (age: X⫽55.3 years, SD⫽12.2 years) than people in our study population, older age and a higher level of pain were associated with a lower likelihood of exercising, whereas living alone, a higher body mass index, and a higher level of education were associated with a higher likelihood of exercising.14 Exercise was measured with a single question (“How often do you engage in regular activities long enough to work up sweat?”). Most (71.4%) of the veterans reported no exercise at all, whereas 28.6% reported some form of activities 1 or more times per week.14 Strengths and Limitations of the Study One of the major strengths of the present study is the simultaneous investigation of several theoretical models of behavioral changes and related variables in the same study population.45,47,48 Furthermore, our study had a high response rate (86%), and the study population accurately represented the inception cohort.2 With regard to the limitations of the present study, we used a crosssectional design and focused on personal and environmental determinants and physical activity behavior at the same time points. Future prospective studies should investigate whether changes in the significant determinants change the physical activity behavior of people with MS over time or across disease periods and investigate ways to help people with MS avoid becoming insufficiently active.

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Additionally, we used a self-report questionnaire to measure physical activity. Self-report questionnaires are used as practical measures of physical activity in large population studies because they are valid, reliable, and easy to administer and have a low cost.49,50 However, questionnaires may result in socially desirable answers, recall bias, and inaccurate scores. On the basis of the assumptions that more intense activities are usually easier to recall and that relatively short episodes of physical activity in daily routines are easily forgotten, the SQUASH may be more valid for more active (healthy) populations.25,26 A meta-analysis of patients with MS showed that the type of physical activity measurement influenced the magnitude of the effects.20 There was a large mean effect size when physical activity was measured with a device such as an accelerometer or a pedometer, whereas there was a smaller mean effect size when it was measured with a self-report survey.20 This type of evidence implies that a device or a performance measure may be more sensitive in detecting differences in physical activity.50 Nevertheless, in populations with abnormal gait patterns, which are common symptoms in patients with MS, little is known about the validity of accelerometers.51,52 Additional clinimetric evidence is needed for both types of physical activity measurements in patients with MS, given that gait and ambulatory abnormalities and cognitive dysfunction may influence their validity and reliability. Furthermore, we chose to use the total physical activity score as the outcome of interest. Studies of other populations with MS (eg, older patients or patients in the precontemplation stage), studies focusing on separate types of physical activity (eg, work-related, leisure-time, and household activities, means of transportation, or sports participation), July 2010

Physical Activity in Multiple Sclerosis and studies of other specific sets of determinants may further increase understanding of physical activity behavior.14,53 Finally, SQUASH scores are based on MET derived from the general population.24,25 For an individual who is healthy, it has been estimated that, compared with sitting quietly, engaging in moderate activity results in a caloric consumption that is 3– 6 times higher (MET⫽3– 6). It is possible, however, that MET for the same activity differs between people who are healthy and people who have MS or even within subgroups of the present study population. Consequently, the absolute values may not be totally accurate; therefore, comparisons with other study populations may be problematic. Further Recommendations One of the key aims of preventive measures in public health is to increase physical activity levels in the general population.11 Physical therapists could play a pivotal role in promoting physical activity. In people with a disability, self-management of their health status and physical activity levels should, of course, be encouraged. Stroud et al47 showed that patients with MS are indeed aware that regular exercise will improve their physical performance. Participants also reported that a perceived benefit of exercise is a sense of personal accomplishment. In that recent study,47 the most highly ranked barriers for exercise were items related to physical exertion (eg, “Exercise tires me,” “I am fatigued by exercise,” and “Exercise is hard work for me”). We identified similar barriers in the present study. Patients with MS need to overcome issues related to physical exertion when undertaking physical activity. Addressing and overcoming individual barriers to exercise may lead to improvements in exercise self-efficacy and subsequently improve exercise July 2010

participation rates, adherence, and maintenance. Patients with MS and a high level of perceived control over fatigue are better able to recognize and determine the boundaries of healthy tiredness while exercising.48 Moreover, these patients experience positive outcomes from exercise. However, patients with a low level of perceived control are less able to monitor their body response to exercise. Furthermore, less control seems to be related to a decrease in adherence and other negative outcomes, such as perceived physical deterioration, unsteady gait, reduced balance, and feelings of failure, anxiety, and loss of safety.54 For each patient with MS, a personal activity plan that integrates preventive and therapeutic physical activities is highly recommended.9 Ideally, such an activity plan should be developed and updated each year, in consultation with a physical therapist or a fitness professional (eg, a sports physical therapist), so that adequate attention is paid to therapeutic and risk management issues related to MS. Patients whose MS precludes activity at the minimum recommended level for prevention should engage in regular MS-specific physical activity programs to avoid sedentary behavior. Indeed, patients in the precontemplation stage (ie, patients who are inactive and have no intention of making changes) are probably the most difficult to persuade that they should become more physically active. As stated by Rimmer,23 understanding the impairments, activity limitations, and participation restrictions of patients with MS, within personal and environmental contexts, is the first step toward designing individually adapted interventions with a greater likelihood of success.

mographic, disease-related, cognitivebehavioral, and environmental characteristics to the physical activity behavior of people with MS. On the basis of the determinants that we investigated, 1 disease-related factor (ie, EDSS scores) and 2 demographic factors (ie, a disability pension and having children to care for) were related to physical activity behavior in 106 people who had had MS for 6 years and explained 37.2% of the variance in their level of physical activity. Dr Beckerman, Dr de Groot, and Dr Lankhorst provided concept/idea/research design, writing, and project management. Dr Beckerman, Dr de Groot, and Dr Scholten provided data collection and data analysis. Dr Beckerman provided fund procurement, participants, facilities/equipment, and institutional liaisons. Ms Kempen and Dr Lankhorst provided consultation (including review of manuscript before submission). The study protocol was approved by the medical ethics committees of the VU University Medical Center, Academic Medical Center, Sint Lucas Andreas Hospital, and Onze Lieve Vrouwe Gasthuis in Amsterdam and by Erasmus University Medical Center in Rotterdam, the Netherlands. This study was carried out as part of the FUPRO-MS II project, “Long-Term Prognosis of Functional Outcome in Neurological Disorders,” and was supported by the Netherlands Organization for Health Research and Development (ZonMw Project: 1435.0020). The material in this article was presented at the 16th European Congress of Physical and Rehabilitation Medicine; June 3– 6, 2008; Bruges, Belgium. This article was submitted October 23, 2009, and was accepted April 1, 2010. DOI: 10.2522/ptj.20090345

References

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1 Multiple Sclerosis Council for Clinical Practice Guidelines. Fatigue and Multiple Sclerosis: Evidence-Based Management Strategies for Fatigue in Multiple Sclerosis. Washington, DC: Paralyzed Veterans of America; 1998. 2 de Groot V, Beckerman H, Lankhorst GJ, et al. The initial clinical course of patients with multiple sclerosis: three-year follow-up study. Mult Scler. 2005;11: 713–718.

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Physical Activity in Multiple Sclerosis 3 de Groot V, Beckerman H, Twisk JWR, et al. Vitality, perceived social support and disease activity determine the performance of social roles in recently diagnosed multiple sclerosis: a longitudinal analysis. J Rehabil Med. 2008;40:151–157. 4 Krupp LB, Christodoulou C. Fatigue in multiple sclerosis. Curr Neurol Neurosci Rep. 2001;1:294 –298. 5 Mathiowetz V, Matuska KM, Murphy ME. Efficacy of an energy conservation course for persons with multiple sclerosis. Arch Phys Med Rehabil. 2001;82:449 – 456. 6 Mulcare JA. Multiple sclerosis. In: American College of Sports Medicine, ed. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. 2nd ed. Champaign, IL: Human Kinetics; 2003:267–272. 7 Petajan JH, Gappmaier E, White AT, et al. Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann Neurol. 1996;39:432– 441. 8 Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423–1434. 9 Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1435–1445. 10 Nusselder WJ, Looman CW, Franco OH, et al. The relation between nonoccupational physical activity and years lived with and without disability. J Epidemiol Community Health. 2008;62: 823– 828. 11 Deshpande AD, Dodson EA, Groman I, Brownson RC. Physical activity and diabetes: opportunities for prevention through policy. Phys Ther. 2008;88:1425–1435. 12 Wendel-Vos GC, Schuit AJ, Feskens EJ, et al. Physical activity and stroke: a metaanalysis of observational data. Int J Epidemiol. 2004;33:787–798. 13 Rietberg MB, Brooks D, Uitdehaag BMJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane Database Syst Rev. 2005;1:CD003980. 14 Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life. Arch Phys Med Rehabil. 2009;90:420 – 428. 15 Mostert S, Kesselring J. Effects of a shortterm exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis. Mult Scler. 2002;8:161–168. 16 Meyer K. Exercise training in heart failure: recommendations based on current research. Med Sci Sports Exerc. 2001;33: 525–531.

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17 Rognmo O, Hetland E, Helgerud J, et al. High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2004;11:216 –222. 18 Vogiatzis I, Nanas S, Roussos C. Interval training as an alternative modality to continuous exercise in patients with COPD. Eur Respir J. 2002;20:12–19. 19 van den Berg-Emons RJ, Bussmann JB, Haisma JA, et al. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge. Arch Phys Med Rehabil. 2008;89:2094 –2101. 20 Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult Scler. 2005;11:459 – 463. 21 van der Ploeg HP, van der Beek AJ, van der Woude LH, van Mechelen W. Physical activity for people with a disability: a conceptual model. Sports Med. 2004;34:639 – 649. 22 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 23 Rimmer JH. Use of the ICF in identifying factors that impact participation in physical activity/rehabilitation among people with disabilities. Disabil Rehabil. 2006; 28:1087–1095. 24 Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 suppl):S498 –S504. 25 Wendel-Vos GC, Schuit AJ, Saris WH, Kromhout D. Reproducibility and relative validity of the Short Questionnaire to Assess Health-Enhancing Physical Activity. J Clin Epidemiol. 2003;56:1163–1169. 26 Wagenmakers R, van den Akker-Scheek I, Groothoff JW, et al. Reliability and validity of the Short Questionnaire to Assess HealthEnhancing Physical Activity (SQUASH) in patients after total hip arthroplasty. BMC Musculoskelet Disord. 2008;9:141. 27 Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an Expanded Disability Status Scale (EDSS). Neurology. 1983; 33:1444 –1452. 28 Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The Fatigue Severity Scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46:1121–1123. 29 Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977; 1:385– 401. 30 Beekman ATF, Deeg DJH, van Limbeek J, et al. Criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D): results from a community-based sample of older subjects in the Netherlands. Psychol Med. 1997;27:231–235. 31 Linn BS, Linn MW, Gurel L. Cumulative Illness Rating Scale. J Am Geriatr Soc. 1968;16:622– 626.

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32 The EuroQol Group. EuroQol: a new facility for the measurement of health-related quality of life. Health Policy. 1990;16: 199 –208. 33 Lamers LM, Stalmeier PFM, McDoneel J, et al. Kwaliteit van leven meten in economische evaluaties: het Nederlands EQ-5Dtarief. Ned Tijdschr Geneeskd. 2005;149: 1574 –1578. 34 Sallis JF, Pinski RB, Grossman RM, et al. The development of self-efficacy scales for health-related diet and exercise behaviors. Health Educ Res. 1988;3:283–292. 35 Kendzierski D, DeCarlo KJ. Physical Activity Enjoyment Scale: two validation studies. J Sport Exerc Psychol. 1991;13:50 – 63. 36 Sallis JF, Hovell MF, Hofstetter CR, et al. A multivariate study of determinants of vigorous exercise in a community sample. Prev Med. 1989;18:20 –34. 37 Marcus BH, Rossi JS, Selby VC, et al. The stages and processes of exercise adoption and maintenance in a worksite sample. Health Psychol. 1992;11:386 –395. 38 van Sluijs EM, van Poppel MN, Stalman WA, van Mechelen W. Feasibility and acceptability of a physical activity promotion programme in general practice. Fam Pract. 2004;21:429 – 436. 39 Sallis JF, Grossman RM, Pinski RB, et al. The development of scales to measure social support for diet and exercise behaviors. Prev Med. 1987;16:825– 836. 40 Neath J, Roessler RT, McMahon BT, Rumrill PD. Patterns in perceived employment discrimination for adults with multiple sclerosis. Work. 2007;29:255–274. 41 Varekamp I, de Vries G, Heutink A, van Dijk FJ. Empowering employees with chronic diseases; development of an intervention aimed at job retention and design of a randomised controlled trial. BMC Health Serv Res. 2008;8:224. 42 Sweetland J, Riazi A, Cano SJ, Playford ED. Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers. Mult Scler. 2007;13:1183–1189. 43 Roessler RT, Rumrill PD Jr, Hennessey ML, et al. Perceived strengths and weaknesses in employment policies and services among people with multiple sclerosis: results of a national survey. Work. 2003;21: 25–36. 44 Lamberg T, Virtanen P, Vahtera J, et al. Unemployment, depressiveness and disability retirement: a follow-up study of the Finnish HeSSup population sample. Soc Psychiatry Psychiatr Epidemiol. 2010;45: 259 –264. 45 Motl RW, Snook EM, Schapiro RT. Symptoms and physical activity behavior in individuals with multiple sclerosis. Res Nurs Health. 2008;31:466 – 475. 46 Prakash RS, Snook EM, Motl RW, Kramer AF. Aerobic fitness is associated with gray matter volume and white matter integrity in multiple sclerosis. Brain Res. 2009 June 25 [Epub ahead of print].

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Physical Activity in Multiple Sclerosis 47 Stroud N, Minahan C, Sabapathy S. The perceived benefits and barriers to exercise participation in persons with multiple sclerosis. Disabil Rehabil. 2009;31:2216 – 2222. 48 Lewis BA, Marcus BH, Pate RR, Dunn AL. Psychosocial mediators of physical activity behavior among adults and children. Am J Prev Med. 2002;23(2 suppl):26 –35. 49 Sallis JF, Saelens BE. Assessment of physical activity by self-report: status, limitations, and future directions. Res Q Exerc Sport. 2000;71:1–14.

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50 Janz KF. Physical activity in epidemiology: moving from questionnaire to objective measurement. Br J Sports Med. 2006;40: 191–192. 51 Houdijk H, Appelman FM, van Velzen JM, et al. Validity of DynaPort GaitMonitor for assessment of spatiotemporal parameters in amputee gait. J Rehabil Res Dev. 2008; 45:1335–1342. 52 de Vries SI, van Hirtum HW, Bakker I, et al. Validity and reproducibility of motion sensors in youth: a systematic update. Med Sci Sports Exerc. 2009;41:818 – 827.

53 Wendel-Vos W, Droomers M, Kremers S, et al. Potential environmental determinants of physical activity in adults: a systematic review. Obes Rev. 2007;8: 425– 440. 54 Smith C, Hale L, Olson K, Schneiders AG. How does exercise influence fatigue in people with multiple sclerosis? Disabil Rehabil. 2009;31:685– 692.

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Research Report

Facilitators and Barriers to Exercising Among People With Osteoarthritis: A Phenomenological Study Unnur Petursdottir, Solveig A. Arnadottir, Sigridur Halldorsdottir U. Petursdottir, PT, MS, is Physical Therapist, Bjarg Rehabilitation Center, Bugdusida 1, 603 Akureyri, Iceland. Mrs Petursdottir was a student at the University of Akureyri, Akureyri, Iceland, at the time this research was completed in partial fulfillment of the requirements for her Master of Science degree in health sciences. Address all correspondence to Mrs Petursdottir at: [email protected]. S.A. Arnadottir, PT, MS, is Assistant Professor, School of Health Sciences, University of Akureyri. S. Halldorsdottir, PhD (Med Dr), is Professor and Chairman of the Faculty of Graduate Studies, School of Health Sciences, University of Akureyri. [Petursdottir U, Arnadottir SA, Halldorsdottir S. Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study. Phys Ther. 2010; 90:1014 –1025.] © 2010 American Physical Therapy Association

Background. Evidence indicates that regular exercise improves the well-being of individuals with osteoarthritis (OA). However, these individuals seem to exercise less frequently than the general population and seem to have limited adherence to exercising. Objectives. The purposes of this study were: (1) to increase knowledge and understanding of the experience of exercising among individuals with OA and (2) to determine what they perceive as facilitators and barriers to exercising.

Design and Method. This study used a qualitative method, based on the Vancouver School of doing phenomenology, involving purposive sampling of 12 individuals and 16 interviews. The participants, 9 women and 3 men, were 50 to 82 years of age.

Results. Extended information on exercise behavior among people with OA is presented in a model in which internal and external facilitators and barriers to exercising are delineated. Based on this model, a checklist is proposed for physical therapists’ assessment of these factors. Internal factors include individual attributes and personal experience of exercising, whereas external factors include the social and physical environment. The participants expressed how each of these internal and external factors could act both as a facilitator and a barrier to exercise participation and the pattern of exercising; for example, the presence of pain was an important aspect concerning internal barriers to exercising, whereas the hope of less pain was one of the main facilitators.

Conclusions. Increased knowledge and understanding of the factors influencing exercise behavior in people with OA can help physical therapists and other health care professionals support them in initiating and maintaining a healthy exercise routine and, consequently, achieving a better quality of life.

Post a Rapid Response to this article at: ptjournal.apta.org 1014

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Facilitators and Barriers to Exercise in People With Osteoarthritis

O

steoarthritis (OA) is the most prevalent of arthritic diseases and has a great influence on activities and participation in the daily life of millions of people worldwide.1,2 The joints of the hips, knees, hands, and spine are those most often affected by OA, and about half of the people with OA have the disease in more than one joint.3 Osteoarthritis is twice as common among women as men, and known risk factors are heredity, obesity, trauma, occupation, malformation of joints, and older age.2 Research indicates that the majority of people with OA in their knees or hips can benefit from strengthening and general fitness exercises to reduce pain and increase fitness and mental well-being.4 –11 The few research results available on people with generalized OA12,13 also indicate that exercise reduces symptoms and increases general function.14,15 However, people with OA seem to exercise less frequently than the general population,16 and exercise adherence is a common problem among these people.17–19

Factors that may play an important role in explaining the exercise behavior of people with OA include self-confidence and self-efficacy,14,17,19 –21 knowledge of the disease and the effects of exercise,14,18,20 –22 the support and attitude of others,14,18,20 –24 mental health,21 and former experience of exercising.14,18,20,22 Pain and stiffness

Available With This Article at ptjournal.apta.org • The Bottom Line Podcast

are common symptoms of arthritis that also can have a significant impact on the attitude and capability of people to exercise,22,25 as well as the common misunderstanding that OA is something that comes naturally with older age and that nothing can be done about it.22,26 Moreover, encouragement by a physician to exercise or the lack of such encouragement has been shown to be of importance.22,27 Despite this important information, more research is needed to increase knowledge and deepen understanding of what determines whether people with OA exercise, given the known beneficial effects of exercise.14 The results from a few qualitative studies on exercise behavior of people with OA18,20,22,23 demonstrate how these goals may be achieved by listening and learning from the life experience of people with OA. One of the main questions the National Institute for Health and Clinical Excellence12 has put forward to

be answered in future research is: Which are the most important factors influencing exercise adherence of people with OA? This study was a response to that call. The focus of the study was on people with OA, with the aim of increasing knowledge and understanding of what they experience as facilitators and barriers to exercising.

Method Research in physical therapy has mainly been conducted within a quantitative paradigm.28 There is, however, an increasing understanding within the physical therapy community that this approach has resulted in a lack of knowledge and viewpoints within the profession, especially regarding the patient’s perspective.29 –31 In the present study, the Vancouver School of doing phenomenology was the method chosen to answer the research question because it has proven useful in increasing knowledge and deepening understanding of human phenomena

The Bottom Line What do we already know about this topic? Pain and stiffness play an important role in explaining exercise behavior of people with osteoarthritis (OA). Various psychological and environmental factors also may have a significant impact.

What new information does this study offer? The results indicated that many internal and external factors, such as past experience with exercise and the physical environment, have a major impact on exercise behavior among people with OA. This information was delineated in a theoretical model, which gave an overview of these factors. A checklist for assessment of facilitators and barriers to exercise was proposed.

If you’re a patient, what might these findings mean for you?

• Audio Abstracts Podcast This article was published ahead of print on May 13, 2010, at ptjournal.apta.org.

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Understanding the factors influencing exercise behavior can help people with OA to initiate and maintain a healthy exercise routine and consequently lead to a better quality of life.

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Facilitators and Barriers to Exercise in People With Osteoarthritis Table 1. The 12 Basic Steps of the Research Process of the Vancouver School of Doing Phenomenology and How They Were Followed in the Present Study Steps in the Research Process

What Was Done in the Present Study

Step 1. Selecting dialogue partners (the sample).

12 participants with osteoarthritis (3 men, 9 women), 50 years of age or older, living in urban areas.

Step 2. Silence (before entering a dialogue).

Preconceived ideas were deliberately put aside.

Step 3. Participating in a dialogue (data collection).

One or 2 interviews with each participant, for a total of 16 dialogues. All the interviews were conducted by the first author.

Step 4. Sharpened awareness of words (data analysis).

Data collection and data analysis were done concurrently.

Step 5. Beginning consideration of essences (coding).

Trying repeatedly to answer the question: What is the essence of what this research participant is saying?

Step 6. Constructing the essential structure of the phenomenon from each case (construction).

The main factors in each participant’s story were highlighted, and the most important factors were constructed into an analytic framework.

Step 7. Verifying each case construction with the relevant participant (verification).

This was done with 4 participants.

Step 8. Constructing the essential structure of the phenomenon from all the cases (constructing the analytic framework).

All of the researchers participated in this final data analysis process and made sure the model and framework constructed were based on the actual data.

Step 9. Comparing the essential structure of the phenomenon with the data (meta-synthesis of all the different case constructions).

To ensure this factor, all the transcripts were read over again.

Step 10. Identifying the overriding theme that describes the phenomenon (constructing the overriding theme).

Facilitators and barriers influencing exercise behavior among people with osteoarthritis were identified.

Step 11. Verifying the essential structure with some research participants (verification).

The results and the conclusions were presented to and verified by 2 participants.

Step 12. Writing up the findings (multivoiced).

The participants are quoted directly to increase the trustworthiness of the findings and conclusions.

within the various fields of health care.32 This qualitative method is characterized by 12 basic steps. Table 1 presents how the steps were followed in the present study. All participants signed an informed consent statement, and actions were taken to protect the participants’ anonymity (eg, by using pseudonyms in all data analyses and reporting of results). Sample A purposeful sample was used in which selection of participants was based on their experience of the phenomenon studied.32 Participants had to have a minimum of 5 years’ history of OA, have symptoms confirmed by radiography, and be 50 years of age or older, as from that age the prevalence of the disease increases considerably.2,3 Furthermore, they had to live in an urban area in order to have comparable ac1016

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cess to health care and exercise facilities, be capable of a dialogue, and be ready to share their own experience of facilitators and barriers to exercising. Advertisements were placed in several rheumatologists’ and physical therapists’ outpatient clinics, as well as in a national newsletter for people with arthritis. All 24 individuals (18 women and 6 men) who volunteered for the study were personally contacted by the first author. Participants were selected in accordance with the variance of the relevant factors involved32 (ie, regarding the number of men and women, different age groups, and people who had had both positive and negative experience of exercising). Fourteen individuals met the inclusion criteria, but saturation was reached when 12 individuals (9 women and 3 men) had been interviewed once or twice. Fur-

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ther information about the sample is shown in Table 2. Data Collection and Data Analysis A total of 16 interviews were conducted in the participants’ homes. Each interview lasted from 30 to 90 minutes (mean⫽53 minutes). Research participants were encouraged to express themselves freely in answering the research questions (Fig. 1). The interviews were taperecorded and transcribed verbatim. The data analysis was based on the Vancouver School of doing phenomenology.32 The transcripts were read through several times, and topics that seemed to have special relevance to the research question were highlighted. In that way, themes were constructed that were finally amalgamated into an analytic framework, in accordance with steps 3 to 6 of the Vancouver School (Tab. 1). July 2010

Facilitators and Barriers to Exercise in People With Osteoarthritis This procedure was repeated for each participant, constantly repeating steps 1 to 6, until we were confident that the whole picture of the participants’ stories had been captured and no new information could be obtained. At that point, saturation was considered to have been reached. No computer software was used for coding or analyzing the data. The results are presented in a model that is encouraged within the Vancouver School.32

Table 2. Participants’ Characteristics (N⫽12) Variable

Value

Age (y), mean (range)

67 (50–81)

Sex, n Female

9

Male

3

History of osteoarthritis symptoms (y), mean (range)

23 (8–35)

Marital status, n Married

9

Single

3

Education, n

Validity and Reliability The research process of the Vancouver School has some built-in strategies designed to increase validity and reliability, particularly steps 7, 9, and 11 (Tab. 1). The researcher triangulation in this study proved fruitful, where the expertise of 3 professionals, 2 physical therapists, and 1 expert in qualitative methods were combined. Triangulation is one of the method’s strategies designed to increase validity and reliability.32 Role of the Funding Source This study was funded by a grant from the Icelandic Physical Therapy Association Scientific Fund. The sponsor reviewed a study proposal, but had no other role in the study.

Results The main results of the study are presented in the model (Fig. 2) representing the participants’ experience, where internal and external facilitators and barriers to exercise are delineated. The internal factors include several themes categorized as individual attributes and personal experience with exercising. The external factors include several themes categorized into social and physical environments. These internal and external factors can act as facilitators or barriers to exercising. In Figure 2, arrows are used to indicate how the internal factors can influence the external factors, and vice versa, and

High school

3

College

7

University

2

Employment, n Full-time

1

Part-time

2

Disability pension

3

Old age pension

6

Localization of osteoarthritis among the participants,a n Knees/hips

10

Vertebral column

a

9

Hands

6

Other joints

3

Nine of the participants reported osteoarthritis symptoms in more than one body region.

how the exercise behavior is influenced by both. The participants who were influenced predominantly by facilitators described themselves as more successful in including exercise as a part of their lifestyle compared with those participants who were more or less predominantly influenced by barriers to exercise. Based on this

information, we constructed a checklist of facilitators and barriers that influence exercise behavior among people with OA (Fig. 3). Internal Factors—Individual Attributes Motivation. The influence of motivation was evident in the study, emerging from various sources. Some participants based their moti-

Can you tell me about your experience of exercising, after the arthritis started to influence your life? • What has encouraged you to exercise? • What has discouraged you from exercising? • Which factors determine whether you continue your exercise routine? • Have you been encouraged by other people to exercise? By whom?

Figure 1. Interview guide.

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Figure 2. Model representing the internal and external facilitators and barriers to exercising among people with osteoarthritis.

vation on the fact that they liked physical activity and, therefore, had been physically active. “I have always enjoyed physical activity” (Audrey). They were eager to find activities and exercise that fitted them and, in many cases, adapted their exercises to their life with OA. We refer to this as motivation by enjoyment. Other participants were motivated by the results of the exercise, not because they liked it or enjoyed it. “I did it because I knew it was good for me, but not because I liked it” (Ellen). We refer to this as motivation by results. One of the partici1018

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pants seemed to lack the motivation to exercise, based on an overwhelming experience of boredom while exercising. She declared that she would never, ever exercise, no matter what. “It is dead boring, so I just don’t do it and never will” (Mary). Personality. The personality traits of adaptability and initiative had a strong influence on the exercise behavior of the participants. “I worked out new ways to cope, to keep my arthritis from getting in the way too much” (Betty). They described the importance of not letting the OA

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control their lives, although its existence should be recognized and respected. Many participants talked about the importance of mental health and the importance of being positive, cheerful, and not lingering on negative circumstances. “I think that general positivism is part of your health; if you think constantly about pain and aches, then you get really sick” (Indy). Self-image. Many of the participants described how they had to fit their OA into their self-image and adapt their lives to it. Some of the July 2010

Facilitators and Barriers to Exercise in People With Osteoarthritis

Figure 3. Facilitators and barriers influencing exercise behavior among people with osteoarthritis.

younger participants seemed frustrated. “I was extremely unhappy with myself. . . . I couldn’t work as hard as before, and I just could not understand why. It was one of the hardest things, to accept myself as July 2010

what I had become” (Audrey). The older participants expressed greater acceptance. “Well, you have to face the fact that you are not young anymore, and you just have to slow down” (Hans).

Health and exercise attitude. Attitudes toward one’s own health and exercise were described. “You cannot let the arthritis overtake you. . . . I was not going to let the arthritis stop me” (Audrey). Addi-

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Facilitators and Barriers to Exercise in People With Osteoarthritis tionally, the participants reflected on what to do in order to remain as healthy as possible. “I have always taken walks and attended gym classes of some kind. That is why I am still standing” (Gerda). Exercise history. The only participant who had never wanted to exercise described her very low endurance as a young adult and her experience of early defeat in sports and physical activities; that is, she had begun early in life with a negative attitude toward exercise, which she was unwilling to review or change. “I played sports when I was young, but then I quit. I never had any endurance, so I was never good at it” (Mary). Her prior, negative experience seemed to have kept her from physical activity during her whole life. Disease knowledge. Participants’ knowledge of both general health and OA was of high importance. “Now I think I handle it more wisely. I know better because I’ve been fortunate to get good instruction” (Audrey). Most of the participants had experienced being educated by their physical therapists. Some participants wondered how to get such information to the public. “There are many 60⫹-year-olds who don’t use computers to get information. And these are the people with arthritis! I think it is much easier to get information to the younger people. We use the Internet” (Audrey). Internal Factors—Personal Experience Effect of pain. Pain was a crucial issue in the interviews, being a barrier in itself, but the hope of decreasing the pain by exercising turned out to be a major facilitator to encourage regular exercise. “I know that when I’m done I feel better. That’s what I’m constantly after” (Nancy). The participants described the difficulty of having to constantly adapt their 1020

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exercise pattern to pain that could vary from day to day and even be too intense to be able to exercise at all. Effect of stiffness and fatigue. Stiffness and fatigue were barriers to exercising. “It was like my body was made of lead” (Kirsten). As with the pain, however, the experience of less stiffness and more stamina turned out to be facilitating. A few of the women mentioned “paralyzing fatigue” as a major barrier for getting anything done and felt it might be related more to mental fatigue than to physical fatigue. One woman expressed her deep concern regarding how pain and fatigue led to difficulties with personal hygiene. She believed that people with chronic pain hesitate to exercise because they do not feel up to taking a shower afterward. “The effort to get clean afterward is really hard. . . . You just don’t have the energy to take a shower” (Kirsten). Finding suitable exercise. The participants described the importance of suitable exercise and their experience of how exercise should progress gradually under the supervision of a qualified person. “I think that physical therapists are the best to help those who have a physical dilemma to start exercising . . . and start carefully, and under supervision. I think that is very important” (Audrey). However, many participants mentioned the importance of finding an enjoyable training mode. “And I think that it is important when people choose which exercises to do, that you enjoy it, that you feel it is rewarding . . . these positive factors have to be present” (Audrey). Perceived benefits of exercising. Many benefits of exercising concerning the OA symptoms were mentioned. Other general effects were mentioned as well, such as increased fitness and a better heart condition. “Exercising has a good effect on ev-

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erything, including the heart” (Carl). Additionally, most of the participants agreed that physical exercise improved their mental well-being. “I am more vivacious, both physically and mentally” (Carl). Participants talked about the importance of keeping their weight down and addressed the concern of gaining weight. “I feel it right away if I gain a pound; I feel it in my hips and knees” (Laura). They also mentioned the connections between impaired mobility and obesity. “Well, if you don’t move, you get fat, no matter how little you eat” (Gerda). Quality of sleep. The significance of a good night’s sleep was a factor that influenced both the inclination and ability to exercise. “Then you get lazy [because of a bad night’s sleep]” (Carl). The participants also described how activity improved sleep. “All activity is good for sleep” (Audrey). External Factors—Social Environment Family support. The support, caring, and encouragement of others were among important external factors influencing how much the participants exercised. “Yes, my wife, naturally, she encourages me” (Carl). Most of the participants seemed to feel the need for such encouragement. Yet, when talking about the family’s attitudes toward the disease and the importance of exercise, some of the women expressed having a hard time justifying to themselves and their families their need to spend time exercising. One of them said about the experience of a nonsupportive husband: “It [the experience of lack of support] was, just, what should I say, totally pathetic. . . . I guess men are not all equally understanding” (Audrey). Physical therapists’ professional care. All participants had some experience with physical therapists, July 2010

Facilitators and Barriers to Exercise in People With Osteoarthritis most of it positive, and many participants placed emphasis on the fact that the encouragement and understanding they received from their physical therapists were very important. “Well, I always say that my physical therapist is as good as any psychologist” (Gerda). The importance of listening and good communication was highlighted and seemed to play a big role in the perceived benefits of physical therapy. Physicians’ encouragement. The encouragement of physicians to exercise was very important to some of the participants. This encouragement (ie, whether physicians emphasized exercise), however, varied. “He encourages me in every way” (Carl). “They have not done it [encouraged exercising]” (Gerda). Whether physicians referred their patients to physical therapists also varied. “They [the physicians] are positive if you ask [for a referral to a physical therapist], but you have to ask” (Gerda). Training partners. Some of the participants emphasized the importance of training partners. “I like exercising in a group the most. . . . I’m more reluctant to go alone into the gym” (Gerda). Other participants preferred to exercise alone. “I like being free when it comes to training time and just decide for myself when I do it and when I don’t” (Betty). Socioeconomic status. The cost of exercising indoors (eg, using a gym) turned out to be a barrier for those participants with low income. “And this costs money. Walking, however, is free. Such things matter when you only have your pension” (Carl). External Factors—Physical Environment Effect of weather. Weather conditions were frequently mentioned. Many of the participants believed July 2010

that weather or climate directly influenced their OA symptoms. “Weather controls almost totally how I feel. I feel good when it’s warm, but horrible when it’s cold and damp. And I’m miserable during high winds” (Kirsten). The participants described how environmental factors such as high winds and icy conditions prevented them from going outdoors to exercise, such as walking. Some participants felt they were more sensitive to cold after they contracted arthritis. Availability of exercise classes. The availability and variety of exercise classes in the participants’ neighborhoods were quite good. Still, the participants mentioned that appropriate exercise classes often were difficult to find, and sometimes it was difficult to get information about them. “The problem was that I never found any that suited me” (Kirsten). “Well, there was this note on the wall saying the aqua-exercise classes are about to start. . . . But for whom?” (Audrey). Accessibility of facilities. Sometimes, the accessibility of training facilities was poor and the equipment not user-friendly. “If I was a boy or a man, I would kick those machines; I hate adjusting them, it takes half the time” (Audrey). The main hindrance to accessibility was stairs. “Walking upstairs is the worst thing for me” (Gerda). When walking outside, the lack of benches was mentioned as a barrier. Transportation. The participants described varying types of transportation. Most participants drove by themselves, but some participants had to rely on other people. “But now I’ve decided to quit driving” (Kirsten). Two participants used a service for disabled people.

Exercise Behavior Self-directed exercise. The majority of the participants exercised independently but in different ways. Swimming in warm, geothermal swimming pools (readily available in Iceland) was the most popular activity. “The swimming pools are what I would recommend to every person with OA” (Nancy). Apart from that, most of the participants went regularly for a walk, some daily. Individual physical therapy. Four participants exercised under the supervision of a physical therapist at the time of the interviews. “What keeps me going now is attending physical therapy sessions” (Gerda). These participants described how the physical therapists kept them going and that the therapists were sometimes the key to going on. Group exercise. Two of the women attended aqua-exercise classes. “I think it is the best exercise class I’ve ever attended” (Audrey). Some had been forced to switch groups based on their OA progression through the years. No exercising. Only one woman did not exercise. “There is nothing that can be done about the OA; therefore, I do nothing” (Mary). She worked part-time and believed that was quite enough activity.

Discussion The results of this study, based on a phenomenological approach, yielded valuable insights into the various internal and external factors influencing exercise behavior among people with OA. Despite the variety of experiences related to exercise behavior, a theoretical model and a practical checklist for physical therapists’ assessments were constructed from the data presenting the essence of these factors, emphasizing whether they act as either fa-

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Facilitators and Barriers to Exercise in People With Osteoarthritis cilitators or barriers to exercising. However, the limitations of this study should be kept in mind when interpreting and implementing the results. First, it is likely that a study of this type is biased toward positivity, because optimists and people with initiative may be more willing to volunteer. Second, advertising for participants in outpatient clinics and a newsletter for people with OA may present a selection bias toward participants with more advanced OA than the general population of people with OA. Third, the results are limited to those participants who could communicate fluently. Finally, as in all qualitative studies, the researchers’ preconceived ideas can cause a bias.32 Influence of Internal Factors The participants in our study drew attention to various motives for exercising. The different sources of motivation are seldom discussed within physical therapy, and the definition of the concept often is vague. Scholars are far from unanimous about what constitutes motivation and have variously described it as instinct, drive, motive, and initiative33,34 and defined it as a mixture of drive and goals.33,35,36 However, our participants expressed motivation in 2 ways: motivation by enjoyment and motivation by results. Motivation by enjoyment is the predominant factor when people perform activities because it makes them feel good during or afterward, whereas motivation by results is predominant when the key factor in exercising is the reward that comes at the end. The majority of our participants enjoyed exercising, although their experience of enjoyment varied. These participants had chosen types of exercise that they enjoyed and thereby managed to sustain motivation and, therefore, adherence to exercising. Other researchers have noted that enjoyment while performing the exercise is one of the factors that is 1022

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very important concerning adherence to exercise among people with OA.14,37 Interestingly, despite the absence of motivation by enjoyment, some of our participants based their exercise adherence on motivation by results; that is, they exercised regularly, as they were convinced that exercising was good for them. These results emphasize the importance of recognizing each individual’s source of motivation, if the plan is to encourage people with OA to exercise. It is vital to check whether motivation by enjoyment is present and, if not, to try to activate motivation by results. If motivation is vague, it might be boosted with education and by emphasizing the expected results, as has been noted in the literature.21 From the results of our study, it seems that exercise is more likely to be engaged in and more effective if motivation by enjoyment is present; therefore, it is worth considering how the enjoyment factor can be increased, such as choosing different kinds of exercises.38,39 Our results indicated a strong connection among internal locus of control, high self-efficacy, and active coping. These are all known psychological factors40 – 42 that have been emphasized in exercise among people with painful conditions, such as OA.14 External locus of control43 seemed to concur with low selfefficacy and more passive coping among our participants. In accordance with Stanton et al,42 adaptation seemed to be a valuable characteristic of our participants who were actively coping, as was general positivism.42 Believing in exercise as a part of the OA treatment was an exercise facilitator for most of our participants, as has been reported in other studies.14,40,41 Whether our participants’ former exercise experience was enjoyable or marked by defeat and surrender seemed to affect their present atti-

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tude toward exercising and to fit Bandura’s theory on self-efficacy,44 which postulates that the more often people have succeeded in the past, the more self-efficacy they have in the present. Those individuals who seem to have no willingness to alter their lifestyle are the hardest to motivate. In order to try to increase self-efficacy and thereby achieve a healthier lifestyle, highlighting possible past positive experience has been tried, as well as pointing out others who do well, despite the disease and its discomfort. Facilitating a positive attitude and getting people in the individual’s social surrounding to do the same also has been tried.14 All of the participants agreed that exercising was good for them, but some individuals had a difficult time putting that belief into practice. Those participants who had managed to make exercise a part of their daily routine experienced good results, which is in accordance with Lin and colleagues’ conclusions that if people with OA exercise regularly, the results can be very good.6 It was evident in the participants’ descriptions that pain was surely a barrier to exercise, but the hope of less pain, or at least bearable pain, was a major facilitator for many participants. Whether or not people with OA include exercise in their lifestyle, the attitude toward pain is a fundamental factor.40,41 Fatigue was most prominent in the descriptions of the participants with general OA. The paralyzing fatigue that these participants described evoked our concerns regarding the possible connections between general OA and fibromyalgia, where chronic fatigue is one of the main symptoms. Furthermore, the results of one study45 indicated that people with OA experience notable amounts of fatigue that affects their lives. Problems with personal hygiene were not addressed in previous studJuly 2010

Facilitators and Barriers to Exercise in People With Osteoarthritis ies we found concerning OA and exercise. This could be a hidden problem facing people with OA, limiting their ability and willingness to participate in exercise. Finding out what level and type of exercise were suitable came with experience to some participants, but other participants were constantly overdoing exercising, with negative consequences. In Roessler and Rasmussen’s study, 15% of the participants dropped out of exercising because they felt the training was too difficult and caused them more pain.15 This is an important point for physical therapists to keep in mind and indicates that sometimes professionals may misjudge the capacity of their clients. The instructions from a Swedish health organization, FYSS, emphasize that people with general OA need to be particularly careful when starting exercising.13 Weight control is one of the main issues that the National Health Service12 emphasizes in the management of OA, and in our study, the effects of exercise on weight control were highlighted by many participants, indicating their awareness of the problem. Influence of External Factors The attitude and support of the immediate family are psychological factors that are of great importance.14 In the clinical guidelines of the National Health Service,12 the importance of family education is emphasized in the treatment of people with OA, a factor that was underscored by our participants. When participants talked about physical therapy and physical therapists, it was clear that communication and a sense of a positive connection were equally as important as the physical results of the therapy. This importance of communication is in harmony with one study reporting July 2010

this factor.46 Professional caring has not been focused on in the physical therapy literature, but it entails how health care professionals care for their clients in a professional way and involves a combination of competence, caring, communication, and connection.47 Good communication and connection between the physical therapist and the person with OA may increase adherence to exercise and thereby improve the results of the exercises.6,10,19,48 Many of the participants stated that their physicians had not emphasized the importance of exercising. However, this is one of the 3 key factors addressed in the new clinical guidelines from the National Health Service12 to physicians concerning the treatment of people with OA. These 3 factors are: (1) education, both for patients and their families; (2) exercises, both strengthening and endurance training; and (3) weight control, if necessary. It is important to bear in mind, however, that some studies have indicated that people tend to underestimate if or how the matter of exercise is discussed in their appointments with rheumatologists.49,50 Our study indicates that weather is important and can be either a facilitator or a barrier to exercise and outdoor activities. The effects of weather on how people with OA feel has been questioned,14 and the results of one study indicated that the weather does affect the general wellbeing of people with OA.51 Our participants complained about the lack of information about what exercise programs were available, and for whom. According to our participants, it is vital to provide sufficient and accessible information on exercise classes, make sure facilities are accessible and user-friendly, and encourage local authorities to provide benches along neighborhood walking paths.

Clinical Implications and Future Research The results of this study include extended information on facilitators and barriers concerning exercise behavior among people with OA. The checklist presented in Figure 3 might serve as a practical tool in physical therapists’ assessment of facilitators and barriers to exercise and subsequent interventions. A person with OA who has strong personal characteristics, such as strong self-efficacy and motivation, along with adaptability and initiative, may be able to maintain a regular exercise routine, despite limiting external factors. If, however, the internal factors, such as self-efficacy, motivation, and health beliefs, are weak, the importance of the external factors is increased. This information should be studied further, as it might be a foundation for a standardized instrument to assess which influential factors are strong and which factors need to be worked on to facilitate exercising by people with OA. Future studies might explore whether internal factors (individual attributes and personal experience) are indeed moderating variables that cause individuals to interpret external factors (social and physical environment) as facilitators or barriers to exercise.

Conclusion The theoretical model and practical checklist on facilitators and barriers to exercising can be of value for physical therapists working in health promotion among people with OA, as well as in other areas of clinical work and in physical therapy education, research, and administration. The results indicate that motivation, adaptability, and other internal and external factors have a major impact on whether exercise is included in the lifestyle of people with OA. The question is not whether to exercise but how, how much, and under what circumstances, and the patients themselves, if able to commu-

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Facilitators and Barriers to Exercise in People With Osteoarthritis nicate well, can help to determine what exercises and what level of participation are effective. Increased knowledge and understanding of the factors influencing exercise behavior in people with OA can help physical therapists and other health care professionals support them in initiating and maintaining a healthy exercise routine and, consequently, achieving a better quality of life. All authors provided concept/idea/research design, writing, data analysis, and consultation (including review of manuscript before submission). Mrs Petursdottir provided data collection, participants, and facilities/equipment. Mrs Arnadottir provided project management. Mrs Arnadottir and Dr Halldorsdottir provided institutional liaisons. This research was presented at the 7th Nordic Physiotherapy Congress; September 23, 2009; Oslo, Norway. This study was approved by The National Bioethics Committee (07– 067-S1) and reported to the Data Protection Committee (S3406). This study was funded by a grant from the Icelandic Physical Therapy Association Scientific Fund. This article was submitted July 1, 2009, and was accepted April 7, 2010. DOI: 10.2522/ptj.20090217

References 1 Hunter DJ, Felson DT. Osteoarthritis. BMJ. 2006;332:639 – 642. 2 Centers for Disease Control and Prevention. Arthritis, data and statistics. Available at: http://www.cdc.gov/arthritis/data_statistics.htm. Accessed September 29, 2007. 3 Fautrel B, Hilliquin P, Rozenberg S, et al. Impact of osteoarthritis: results of a nationwide survey af 10,000 patients consulting for OA. Joint Bone Spine. 2005;72: 235–240. 4 Deyle GD, Allison SC, Matakel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301–1317. 5 Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88:123–136.

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6 Lin SY, Davey RC, Cochrane T. Community rehabilitation for older adults with osteoarthritis of the lower limb: a controlled clinical trial. Clin Rehabil. 2004;18: 92– 101. 7 O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999;58:15–19. 8 Petrella, RJ. Is exercise effective treatment of osteoarthritis of the knee? West J Med. 2001;174:191–196. 9 Smidt N, de Vet HC, Bouter LM, et al. Effectiveness of exercise therapy: a bestevidence summary of systematic reviews. Aust J Physiother. 2005;51:71– 85. 10 Thomas KS, Muir KR, Doherty M, et al. Home based exercise programme for knee pain and knee osteoarthritis: a randomised controlled trial. BMJ. 2002;325:752. 11 van Baar ME, Assendelft WJ, Dekker J, et al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomised clinical trials. Arthritis Rheum. 1999;42: 1361–1369. 12 National Health Service, National Institute for Health and Clinical Excellence. Osteoarthritis: the care and management af osteoarthritis in adults. Available at: http:// www.nice.org.uk/nicemedia/pdf/CG59quick refguide.pdf. Accessed March 4, 2008. 13 Roos E. Artros. Available at: http://www. svenskidrottsmedicin.se/fyss/pdf/16_Artros. pdf. Accessed April 23, 2008. 14 Marks R, Allegrante JP. Chronic osteoarthritis and adherence to exercise: a review of the literature. J Aging Phys Act. 2005; 13:434 – 460. 15 Roessler K, Rasmussen PV. Slidgigt, fysisk aktivitet og fastholdelse: evalueringen af “Motion på Recept.” Available at: http://www.cisc.sdu.dk/Publikationer/ qKKR2006_5.pdf. Accessed October 2, 2007. 16 Hootman JM, Macera CA, Ham SA, et al. Physical activity levels among the general US adult population and in adults with and without arthritis. Arthritis Rheum. 2003; 49:129 –135. 17 Belza B, Topolski T, Kinne S, et al. Does adherence make a difference: results from a community-based aquatic exercise program. Nurs Res. 2002;51:285–291. 18 Campell R, Evans M, Tucker M, et al. Why don’t patients do their exercises: understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. J Epidemiol Community Health. 2001;55:132–138. 19 Sullivan T, Allegrante JP, Peterson MG, et al. One-year followup of patients with osteoarthritis of the knee who participated in a program of supervised fitness walking and supportive patient education. Arthritis Care Res. 1998;11:228 –233. 20 Thorstensson CA, Roos EM, Petersson IF, Arvidsson B. How do middle-aged patients conceive exercise as a form of treatment for hnee osteoarthritis? Disabil Rehabil. 2006;28:51–59.

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21 Damush TM, Perkins SM, Mikesky AE, et al. Motivational factors influencing older adults diagnosed with knee osteoarthritis to join and maintain an exercise program. J Aging Phys Act. 2005;13: 45– 60. 22 Hendry M, Williams NH, Markland D, et al. Why should we exercise when our knees hurt: a qualitative study of primary care patients with osteoarthrits of the knee. Fam Pract. 2006;23:558 –567. 23 Veenhof C, van Hasselt TJ, Ko ¨ ke AJ, et al. Active involvement and long-term goals influence long-term adherence to behavioural graded activity in patients with osteoarthritis: a qualitative study. Aust J Physiother. 2006;52:273–278. 24 Rejeski WJ, Brawley LR, Ettinger W, et al. Compliance to exercise therapy in older participant with knee osteoarthritis: implications for treating disability. Med Sci Sports Exerc. 1997;29:977–985. 25 Carson MG, Mitchell GJ. The experience of living with persistent pain. J Adv Nurs. 1998;28:1242–1248. 26 Hurley MV. Muscle, exercise and arthritis. Ann Rheum Dis. 2002;61:673– 675. 27 Iversen MD, Fossel AH, Ayers K, et.al. Predictors of exercise behaviour in patients with rheumatoid arthritis 6 months following a visit with their rheumatologist. Phys Ther. 2004;84:706 –716. 28 Plack MM. Human nature and research paradigms: theory meets physical therapy practice. The Qualitative Report. 2005; 10:223–245. 29 Greenfield BH, Greene B, Johanson, MA. The use of qualitative research techniques in orthopedic and sports physical therapy: moving toward postpositivism. Physical Therapy in Sport. 2007;8:44 –54. 30 Iversen MD. CARE IV Series: state of knowledge, practice, and translation in interdisciplinary arthritis research and care. Phys Ther. 2007;87:1574 –1576. 31 Shephard KF. Mary McMillan Lecture. Are you waving or drowning? Phys Ther. 2007;87:1543–1554. 32 Halldorsdottir S. The Vancouver school of doing phenomenology. In: Fridlund B, Hildingh C, eds. Qualitative Research Methods in the Service of Health. Lund, Sweden: Studentlitteratur. 2000;47– 81. 33 Bernstein DA, Penner LA, Clarke-Stewart A, Roy EJ. Psychology. 7th ed. Boston, MA: Houghton Mifflin; 2006. 34 Motivation. In: Encyclopaedia Britannica Online. Available at: http://www.britannica. com/eb/article-9108744. Accessed April 23, 2008. 35 Feldman RS. Development Across the Life Span. Upper Saddle River, NJ: Pearson Prentice Hall; 2005. 36 Myers DG. Psychology. 7th ed. New York, NY: Worth Publishers; 2004. 37 Schoster B, Callhan LF, Meier A, et al. The People With Arthritis Can Exercise (PACE) Program: a qualitative evaluation of participant satisfaction. Prev Chronic Dis. 2005; 2:A11.

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Facilitators and Barriers to Exercise in People With Osteoarthritis 38 Allegrante JP, Marks R. Self-efficacy in management of osteoarthrits. Rheum Dis Clin North Am. 2003;29:747–768, vi–vii. 39 Fongen C, Husebo ¨ ME, Klokkerud M, Dagfinrud H. Adapted physical activity for patients with rheumatic disease. Lecture presented at: 11th Reumatology Conference; September 12–15, 2007; Reykjavik, Iceland. 40 McPherson KM, Brander P, Taylor WJ, McNaughton HK. Living with arthritis: what is important? Disabil Rehabil. 2001; 23: 706 –721. 41 Michael SR. Integrating chronic illness into one’s life: a phenomenological inquiry. J Holist Nurs. 1996;14:251–267. 42 Stanton AL, Revenson TA, Tennen H. Health psychology: psychological adjustment to chronic disease. Annu Rev Psychol. 2007;58:565–592. 43 Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr. 1966;80(1):1–28.

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44 Bandura A. Self-efficacy mechanism in physiological activation and healthpromoting behavior. In: Madden J, ed. Neurobiology of Learning, Emotion and Affect. New York, NY: Raven Press; 1991: 229 –269. 45 Power JD, Badley EM, French MR, et al. Fatigue in osteoarthritis: a qualitative study. BMC Musculoskelet Disorders. 2008;9:63. Available at: http://www. biomedcentral.com/1471–2474/9/63. Accessed April 19, 2010. 46 Potter M, Gordon S, Hamer, P. The physiotherapy experience in private practice: the patients’ perspective. Aust J Physiother. 2003;49:195–202. 47 Halldorsdottir S. Caring and Uncaring Encounters in Nursing and Health Care: Developing a Theory [dissertation]. Linko ¨ping University Medical Dissertations, No. 493; Linko ¨ ping, Sweden; 1996.

48 Carr A. Barriers to the effectiveness of any intervention in OA. Best Practice Research Clinical Rheumatoly. 2001;15:645– 656. 49 Iversen MD, Eaton HM, Daltroy LH. How rheumatologists and patients with rheumatoid arthritis discuss exercise and the influence of discussions on exercise prescriptions. Arthritis Rheum. 2004;51: 63–72. 50 Iversen MD, Fossel AH, Daltroy LH. Rheumatologist-patient communi- cation about exercise and physical therapy in the management of rheumatoid arthritis. Arthritis Care Res. 1999;12:180 –192. 51 McAlindon T, Formica M, Schmid CH, Fletcher J. Changes in barometric pressure and ambient temperature influence osteoarthrits pain. Am J Med. 2007;120: 429 – 434.

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Research Report Psychometric Properties of a Peer-Assessment Program to Assess Continuing Competence in Physical Therapy Patricia A. Miller, Marla Nayer, Kevin W. Eva P.A. Miller, PT, PhD, is Associate Clinical Professor, School of Rehabilitation Science, McMaster University, IAHS Room 403, 1400 Main St West, Hamilton, Ontario, Canada, L8S 1C7, and currently holds the Raymond and Margaret Labarge Post-doctoral Fellowship for Research and Knowledge Application for Optimal Aging, School of Social Work, McMaster University. Address all correspondence to Dr Miller at: [email protected]. M. Nayer, PT, PhD, is Lecturer, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada. At the time this work was completed, she was Director, Quality Management, College of Physiotherapists of Ontario, Toronto, Ontario, Canada. K.W. Eva, PhD, is Associate Professor, Department of Clinical Epidemiology and Biostatistics, McMaster University. [Miller PA, Nayer M, Eva KW. Psychometric properties of a peerassessment program to assess continuing competence in physical therapy. Phys Ther. 2010; 90:1026 –1038.] © 2010 American Physical Therapy Association

Background. The College of Physiotherapists of Ontario implemented an Onsite Assessment to evaluate the continuing competence of physical therapists. Objective. This study was undertaken to examine the reliability of the various tools used in the Onsite Assessment and to consider the relationship between the final decision and demographic factors.

Design. This was a psychometric study. Methods. Trained peer assessors (n⫽63) visited randomly selected physical therapists (n⫽106) in their workplace. Fifty-three physical therapists were examined by 2 assessors simultaneously. The assessment included a review of practice issues, record keeping, billing practices, the physical therapist’s professional portfolio, and a chart-stimulated recall process. The Quality Management Committee made the final decision regarding the physical therapist’s performance using the assessor’s summary report. Generalizability theory was used to examine the interrater reliability of the tools. Correlation coefficients and regression analyses were used to examine the relationships between demographic factors and performance.

Results. The majority of the physical therapists (88%) completed the program successfully, 11% required remediation, and 1% required further assessment. The interrater reliability of the components was above .70 for 2 raters’ evaluations, with the exception of billing practices. There was no relationship between the final decision and age or years since graduation (r⬍.05).

Limitations. Limitations include a small sample and a lack of data on systemrelated factors that might influence performance. Conclusions. The vast majority of the physical therapists met the College of Physiotherapists of Ontario’s professional standards. Reliability analysis indicated that the number of charts reviewed could be reduced. Strategies to improve the reliability of the various components must take into account feasibility issues related to financial and human resources. Further research to examine factors associated with failure to adhere to professional standards should be considered. These results can provide valuable information to regulatory agencies or managers considering similar continuing competence assessment programs.

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Competence Assessment in Physical Therapy

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rofessional competence has been defined as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.”1(p226) Competence includes the ability to practice safely throughout a person’s career, the ability to assimilate changes in the profession into one’s practice, and the ability to deal with complex situations.2 Continuing competence is defined by the Federation of State Boards of Physical Therapy (FSBPT) as the “ongoing application of professional knowledge, skills and abilities which relate to occupational performance objectives in the range of possible encounters that is defined by that individual’s scope of practice and practice setting.”3 As autonomous health care professionals, physical therapists are expected to demonstrate competence within the context of their practice environment and their role description.4 The efforts to maintain competence require “a commitment to a lifelong process of education and skill development to meet the ever-changing needs of health care.”5(p145) Although it is suggested that health care professionals engage in selfassessment to monitor their own competence and guide professional development activities, there is little evidence to show that this practice is effective.6 – 8 Indeed, the literature on the accuracy of self-assessment among physical therapists suggests that the self-assessment skills of a physical therapist are not completely accurate, with those individuals whose performance is the poorest being most likely to have the least accurate self-assessments.6 Thus, more rigorous measures of competence, such as standardized written tests or peer feedback, are necessary to assist physical therapists in ascerJuly 2010

taining their professional strengths and weaknesses and guiding their professional development activities.6 Furthermore, evidence from various continuing competency assessment programs undertaken by regulatory agencies for physicians indicates that as many as 10% to 12% of physicians require interventions to address performance difficulties.9 –11 Similarly, up to 14% of pharmacists in a Canadian provincial jurisdiction have been found to not meet professional standards.12 For these reasons, formal programs to assess the continuing competence of health care professionals, including physical therapists, should be implemented. These programs are occasionally implemented in the workplace by management, but more commonly they are implemented by state or provincial authorities. This is the case in Ontario, Canada, where the assessment of competence is mandated by the government through the Regulated Health Professions Act (1991).13 There are currently no research reports regarding the psychometric properties of any tool or process to examine continuing competence in physical therapy. There are, however, a limited number of research reports that describe the psychometric properties of tools used to assess the continuing competence of other health care professionals. For example, the chart-stimulated recall (CSR) process, involving evaluation by peers, has been found to be a reliable and valid method to assess competence in several professional disciplines.9,14,15 In the CSR process, an interviewer uses an interview script to gain information about the care provided to patients, addressing areas such as the assessment of the patient, intervention planning and implementation, and evaluation of outcomes. In a study undertaken in occupational therapy, 2 occupational therapy faculty members as-

sessed 12 occupational therapists on 2 occasions using a CSR process. The faculty members reviewed the care provided to patients using 10 charts on each occasion. Salvatori and colleagues14 reported high interrater reliability (intraclass correlation coefficient [ICC]⫽.97) and low inter-case reliability (ICC⫽.44). A CSR process also was part of the practice assessments used to examine the continuing competence of family physicians practicing in Ontario. Norman and colleagues9 examined the reliability of the various tools used by the College of Physicians and Surgeons of Ontario, which included a CSR process, an oral examination, standardized patients, a multiple-choice examination, and 5 objective, structured clinical examination stations. Intraclass correlation coefficients for interrater reliability ranged from .75 to .90 for the CSR process, from .68 to .79 for the oral examination, and from .72 to .79 for the standardized patients.9 Building on the lessons learned from these studies within both occupational therapy and medicine, a program to assess the continuing competence of physical therapists was introduced by the College of Physiotherapists of Ontario (CPO) through its Quality Management Program.16 It was developed in response to government legislation that required all agencies of regulated health care professions in Ontario to develop a program to assess the continuing competence of its licensed registrants. The CPO is the largest physi-

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Competence Assessment in Physical Therapy cal therapist regulatory agency in Canada (akin to a state board in the United States), with approximately 6,100 registrants. In the CPO’s Onsite Assessment, trained peer assessors meet with randomly selected physical therapists in their workplace and use discussion and document review to evaluate the registrants’ adherence to the CPO’s Standards for Practice for Physiotherapists, as described below and, in greater detail, on the CPO’s Web site.17 Adherence to expectations regarding ethical practice outlined in the CPO’s Code of Ethics18 also was included, as was knowledge about certain sections of relevant legislation and regulations that govern the practice of physical therapists in the province. The Quality Management (QM) Committee, a statutory committee defined in provincial regulation, oversaw the Onsite Assessment process. A description of the entire Quality Management Program and a copy of the precise evaluation forms used can be accessed from the CPO Web site.19,20 Van der Vleuten21 has provided a conceptual model with which to describe the utility of assessment methods. Utility has a multiplicative function of 5 variables with differential weights: reliability, validity, educational impact, acceptability, and feasibility.21,22 Indeed, developers of assessment programs need to identify the elements of the assessment that are most important for the context and purpose of the assessment and recognize that compromises will always need to be made for practical purposes. For example, if the assessment is to be formative (eg, intraining assessment), the assessment developers might consider compromising on reliability in favor of the educational impact of the measure. If the purpose of the assessment is to be summative, the reliability and validity aspects of the assessment will be most important. The essence of 1028

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competence assessment is to attempt “to approximate the real professional or educational world as closely as possible, while maintaining standardized test-taking conditions,”21(p62) and these 5 qualities must be balanced in the process. Although it is clear that it is difficult to quantify some of the variables in the model, the relationship among the variables is conceived as multiplicative because if the value of any variable were zero, the utility of the assessment method would be zero.21 This study was undertaken to assess the extent to which peer assessment can provide valuable information for measuring the continuing competency of physical therapists through the Onsite Assessment. Specifically, the objectives of the study were: (1) to determine the reliability of the various tools comprising the Onsite Assessment and (2) to examine the relationships among the final decision of the QM Committee, demographic factors, and the results of the various components of the Onsite Assessment (including the assessors’ summary report) to determine which information most influenced the committee’s decision making.

Method Development of the Onsite Assessment The development of the Onsite Assessment was led by the Director, Quality Management, in collaboration with a small group of physical therapists interested in the Quality Management Program, staff at the CPO, the QM Committee, and the Council of the CPO. Although it is beyond the scope of this article to describe the process that took place over an approximately 6-month period, a brief summary will be provided. Further information can be obtained by contacting the coauthor (M.N.). The Onsite Assessment was developed during a 2-day workshop. A small group of physical therapists

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(n⫽8 –10) were strategically selected to represent various clinical practice areas (musculoskeletal, neurology, cardiorespiratory), geographic areas of the province (urban and rural), and professional roles (clinicians, professional practice leaders, educators). The first day was facilitated by the Director, Quality Management, and was devoted to development of the Practice/Facility Evaluation, the Record Keeping Evaluation, the Billing Evaluation, and the Portfolio Review. The second day was facilitated by a consultant with experience in developing a CSR process for occupational therapists and was devoted to development of the CSR tool. Various CPO documents (eg, Standards of Practice for Physiotherapists,17 Essential Competency Profile for Physiotherapists in Canada,23 and various CPO standards documents) were used extensively on both days to develop the questions and areas of focus for the assessment. The group discussed standards of practice that were amenable to a peer-review process and could be used in the assessment of continuing competence. For example, physical therapists are expected to: (1) maintain a body of specialized technical knowledge, (2) exercise reasoned judgment in the application of that knowledge, and (3) engage in lifelong learning activities. The various tools or processes by which these standards could be assessed were identified and discussed. The following processes and tools were selected as ways of enabling peer reviewers to judge whether these standards were met: a CSR process to address patient care, a review of the physical therapist’s professional portfolio to address his or her learning needs and professional development activities, and the completion of a self-administered questionnaire that tested knowledge of various standards of practice and July 2010

Competence Assessment in Physical Therapy focused discussions to address record-keeping and billing practices. It should be noted that the provincial regulation (ie, Physiotherapy Act, 1991, Ontario Regulation 532/98)24 permits CPO staff or its delegates (ie, assessors) to access any patient charts necessary to conduct CPO business (eg, examining continuing competence), and assessors are bound by the confidentiality provisions in the Regulated Health Professions Act (1991).13 Following these meetings, a summary document was compiled by the Director, Quality Management, and circulated to the working group for review. Feedback was incorporated by the Director, and the proposed program was reviewed by the QM Committee and subsequently by the Council of the CPO, with recommended revisions incorporated. This iterative and collaborative process established the content validity of the Onsite Assessment. Subsequently, there was a pilot test of the Onsite Assessment to examine the feasibility of the process, train assessors, and finalize the scoring scheme. A detailed document outlining the results of the pilot test is available on the CPO Web site.25 The Onsite Assessment The Onsite Assessment is intended to foster an environment that supports physical therapists in selfdirected goals toward lifelong learning, while providing the opportunity to demonstrate continuing competence.16 As part of the Onsite Assessment, the assessor reviews the performance of the physical therapist in terms of the expected standards of practice described by the CPO in its effort to protect the public. When a physical therapist is randomly selected from the CPO database to undergo the Onsite Assessment, a peer assessor makes a half-day visit to his or her workplace. The peer assessor undertakes a review of the regisJuly 2010

trant’s professional portfolio, which is to include 3 parts: (1) a curriculum vitae (CV), including professional development activities, (2) a learning plan, and (3) a completed Professional Issues Self-Assessment (PISA), a self-assessment questionnaire that assists registrants in identifying whether they are up-to-date on the CPO’s standards of practice relevant to their work. The assessor conducts a walkabout of the workplace with the physical therapist and reviews a variety of issues related to the facility and the registrants’ practice. The assessor also examines the recordkeeping practices of the registrant using 6 to 8 charts selected by the registrant and subsequently conducts a CSR process involving those same charts to discuss the provision of patient care. When relevant, the assessor reviews the billing practices (eg, for registrants in private practice or in long-term care facilities). A description of the components of the Onsite Assessment is provided in Appendix 1. For each of the components, the assessors used a scoring form that outlined the specific questions to review with the physical therapist in order to cover all of the required material in a standardized manner. These forms can be downloaded from the CPO Web site.20 At the time of this study, the QM Committee had proposed that 50 physical therapists be randomly identified for assessment each month using a computer-generated algorithm. This number would ensure that all physical therapists would be assessed within a 10-year period. To be eligible, physical therapists had to be working in clinical practice, not assessed in the previous 5 years, and registered for at least 3 years. Selected physical therapists received notification by mail that they had 3 months to complete the process, along with a detailed outline of the Onsite Assessment process. The therapists were asked

to contact the CPO to confirm their participation and to discuss any questions about the process. It was possible for the therapists to defer their participation for valid personal or professional reasons (eg, personal illness, maternity leave). Selected physical therapists were expected to prepare for their assessment by reviewing all of the material received from the CPO. The scoring forms used by the assessor were provided to the registrants to ensure they were knowledgeable about what the Onsite Assessment would involve and what questions would be asked.20 They were expected to prepare their portfolios according to specified requirements and to identify 6 to 8 charts for the recordkeeping review and CSR process. Guidelines for chart selection were provided. They included the requirements that 1 to 2 charts be related to recently discharged patients. Preferably, patients should have been seen over a period of time, not seen once and discharged, and the charts were to reflect a variety of diagnoses, so that not all patients had the same condition. If the therapist performed any controlled acts, one chart should include a patient for whom the controlled act was performed.26 There are 13 controlled acts in Ontario. These are acts restricted to those professions that have been granted the authority to perform them. The controlled acts that physical therapists are authorized to perform are suctioning (also granted to respiratory therapists, physicians, and nurses) and spinal manipulation (also granted to chiropractors and physicians).26 Each randomly selected physical therapist was matched with an assessor who practiced in a similar practice area (eg, if the therapist was working primarily with neurological clients, the assessor would be someone with similar clientele). All peer

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Competence Assessment in Physical Therapy assessors had at least 5 years in practice and were selected by the CPO for the purpose of peer assessment. All peer assessors had attended a 2-day assessor training workshop to prepare for this role. Included in the training was a session led by the Director, Quality Management, which was devoted to the discussion of scoring the various components using the response options, based on the principles outlined by the CPO documents (eg, Standards of Practice for Physiotherapists,17 Essential Competency Profile for Physiotherapists in Canada23) and the CPO mandate of protection of the public. A “present” or “absent” rating was used for the 3 portfolio sections, and a 4-point response format was used for the other 4 components of the Onsite Assessment. The 4 potential responses were “satisfactory,” “needs minor improvements,” “needs major improvements,” and “unacceptable practice” and were determined by the judgment of the trained peer assessor. During the training workshop, considerable time was spent reviewing the various CPO documents and discussing the application of the standards of practice. Assessors were told that the expectation was for physical therapists to be practicing at a level acknowledged by the community as reasonable practice. This approach was similar to the intent of the American Physical Therapy Association’s definition of continued competence as “a component of professional development that addresses the minimum requirements of contemporary practice.”27 Time in the training workshop was allotted to a discussion among assessors and CPO staff regarding the various standards and acceptable performance, based on that expectation. The peer assessor visited the physical therapist’s workplace for approximately 4 hours and carried out the Onsite Assessment. The assessor pro1030

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vided formative feedback to the therapist throughout the process. For example, the assessor would offer suggestions about how to ensure the record keeping better met CPO standards, additional management strategies to consider for the therapist’s patients, or how to improve the organization of the therapist’s professional portfolio and its contents. The assessor completed a summary report and forwarded the completed materials (summary report and all rating sheets) to the QM Committee. The summary report included comments and a rating regarding the overall performance of the physical therapist using same 4-point response format described above. The QM Committee made the final decision about the therapist’s performance based on its review of the documentation and ratings from the peer assessor. There were 5 possible outcomes the QM Committee could assign: completed successfully, completed with recommendations, selfdirected remediation required, QM Committee remediation required, and reassessment required. Appendix 2 provides a full description of the various outcomes. Upon completion of the assessment, the Director forwarded a letter to the therapist outlining the QM Committee’s decision.

for the assessment of at least one physical therapist prior to assuming the role of primary assessor. In the case where there were 2 assessors, the primary assessor’s evaluation and summary report were forwarded to the QM Committee.

A subset of physical therapists (n⫽53) comprised a sample of convenience that was assessed by 2 assessors simultaneously to enable examination of the interrater reliability of the different components within the Onsite Assessment. The allocation of the 2 assessors was influenced by feasibility factors (ie, identifying 2 assessors with similar clinical practice areas and practice settings who lived in reasonable proximity to the registrant). For each assessment, one physical therapist was designated as the “primary assessor” and the other as the “observer.” All novice assessors were observers

Descriptive analyses were used to identify the frequency of the results of the Onsite Assessment and the demographic data regarding the registrants and assessors. Generalizability theory was used to calculate the reliability of each of the 7 components (including the portfolio sections) of the Onsite Assessment, as well as of the rating assigned to the summary report.28 –30

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Data Analysis An “anonymized” database was received from the CPO with the results of the first 3 months of the Onsite Assessment (January–March 2005). It included each registrant’s demographic information of age, graduation year, educational credentials, and area of practice (eg, orthopedics, neurology). The variable “years since graduation” was determined by subtracting the year of graduation from 2005. The database also included the ratings of the various components from the primary assessor and the observer-assessor (when present), the summary report, and the QM Committee’s final decision. For the purpose of the analyses, the categories of responses for the peer assessor and QM Committee decisions listed in the previous section were coded ordinally as 1 through 4 and 1 through 5, respectively. Statistical analyses were conducted using SPSS 13.0 for Windows, Graduate Student Version,* and Excel 2004 for Macintosh, version 11.0.†

* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. † Microsoft Corp, One Microsoft Way, Redmond, WA 98052-6399.

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Competence Assessment in Physical Therapy Mathematically, reliability is a proportion (ranging from 0 to 1) indicating how much variance in scores can be attributed to the participants, which in our case would be the physical therapists, as opposed to that attributable to measurement error induced by differences between raters and the interaction between raters and participants, for example. Conceptually, interrater reliability can be thought of as the strength of the association between the ratings assigned to the physical therapists by one rater and those assigned by another rater. Inter-case reliability, by analogy, can be thought of as the strength of association between the ratings assigned to physical therapists on one patient case and those assigned on another case. Generalizability theory enables us to consider the impact of multiple sources of error (eg, raters and patient case differences) at the same time, thereby allowing the dual advantages of generating estimates of reliability that better account for potential sources of error than ICCs, while allowing the analyst to determine how reliability could be optimized by varying the number of observations that are averaged.28 –30 This latter process is known as a “decision study” (D-study) and, in effect, builds on the general notion that an average score tends to be more trustworthy than a single observation, as error becomes diluted when averaging across multiple observations. G coefficients range between 0 and 1, with 0.75 or higher typically being treated as a threshold for high-stakes decision making.28 –30 Although the results of a D-study are a prediction of the reliability expressed across potential scenarios (eg, involving different numbers of raters and cases), they provide invaluable information to program developers about how widely different sources of variance should be sampled, which, in turn,

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can guide future modifications.30

program

Interrater reliability was assessed for all components of the Onsite Assessment using a subset of 53 physical therapists whose performance was reviewed by 2 peers, one as an assessor and the other as an observer. For the CSR process, both rater and case (ie, patient charts) were variables in the data collected, thus allowing both an interrater and inter-case assessment of reliability.28 A minimum of 6 cases per physical therapist were expected to be available for the 53 physical therapists. However, 7 of the 318 scores (6 ⫻ 53) were missing (2%) and were subsequently replaced with the mean score of all of the documented scores (using both assessors’ ratings) on that therapist’s record. The variance components derived from the generalizability study were submitted to a D-study to estimate the reliability in different hypothetical scenarios where the number of charts examined by 1 or 2 assessors increased from 1 to 6 charts. Spearman correlation analyses and multiple regression analyses were used to consider the relationships between the demographic factors and the QM Committee’s final decision, between the assessment instruments, and between individual instruments and the QM Committee’s final decision. Summarizing the ratings generated from Likert scales and submitting them to parametric statistical analysis can be done without concern.31 Mean scores were computed for the various components of the Onsite Assessment when a pair of assessors had undertaken the assessment, and the single assessor’s score was used if there was not a pair of ratings. For the regression analysis, the mean scores for the summary report, record keeping, CSR process, facility and practice report, and billing were used as independent vari-

ables. The actual scores (present or absent) for PISA, CV, and professional development ratings were used, but the data from 2 physical therapists were removed from the regression analysis because the assessor and observer provided different scores. Interactions between variables were left out due to sample size constraints. Role of the Funding Source This research was funded by a Strategic Training Fellowship in Rehabilitation Research to Dr Miller from the Institute of Musculoskeletal Health and Arthritis of the Canadian Institutes of Health Research.

Results The Registrants In the initial 3 months of the Onsite Assessment, 106 physical therapists were assessed. Some demographic information was missing for 4 of the 106 registrants. The mean age of the therapists (n⫽103) was 42 years (SD⫽9.5), with a mean time since graduation of 18 years (SD⫽10.7). The professional (entry-level) qualification was a baccalaureate degree for the majority of the therapists (73%) and a diploma in physical therapy for the others (27%). The modal area of practice, as described by the physical therapists (n⫽102), was orthopedics (46%). The remaining therapists identified their area of practice as general (all areas) (15%), neurology (7%), and rehabilitation (7%), with other areas (eg, respirology, sports medicine, critical care, rheumatology) comprising the remaining 25%. The majority of the physical therapists (63%) were in private practice. The majority of the physical therapists (88%, n⫽93) completed the program successfully, 11% (n⫽12) were deemed to require a remediation program, and 1 therapist (1%) was thought to need reassessment. Table 1 shows the final decisions of

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Competence Assessment in Physical Therapy Table 1.

sports medicine, rheumatology) comprising the remaining 17%.

Final Decisions of the Quality Management Committee (N⫽106) Decision

Percentage

Completed program successfully (n⫽75)

71

Completed program with recommendations (n⫽18)

17

Self-directed remediation required (n⫽9)

9

Quality Management Committee remediation required (n⫽3)

3

Reassessment required (n⫽1)

1

the QM Committee. Scores of the therapist who required reassessment were removed from subsequent analyses due to concerns regarding the validity of assessment findings. Table 2 shows the ratings of the primary assessor on the various components of the Onsite Assessment. The Assessors The assessments were undertaken by a total of 63 different assessors, 21 of whom served as both assessor and observer when the interrater reliability study was conducted. The mean age of the assessors was 44 years (SD⫽8.2), with a mean time since graduation of 19 years (SD⫽7.6). For the majority of assessors (75%), the professional (entry-level) qualification was a baccalaureate degree, with the remaining assessors (25%) having received a diploma. The larg-

est number of assessors were working in private practice (n⫽24, 38%), with general hospitals (n⫽12, 19%) and home visiting agencies (including the Community Care Access Centre) (n⫽10, 16%) as the next most frequent work settings. The remaining work settings (27%) included long-term care and continuing care facilities, rehabilitation centers, pediatric facilities, and governmentfunded clinics. There was 1 individual for whom data regarding primary area of practice were missing. The modal primary area of practice for the assessors (n⫽62) was identified to be orthopedics (52%). The remaining assessors identified their primary area of practice as general (all areas) (21%) or neurology (10%), with other areas (eg, respirology, cardiology, critical care, administration, rehabilitation,

Objective 1: Reliability of the Onsite Assessment The interrater reliability of the various components was moderate to good in all instances, with the exception of the assessment of billing practices, as illustrated in Table 3. As described above, the reliability of the average of multiple observations tends to be higher than the reliability of a single observation. As such, G1 in Table 3 indicates the extent to which a single rater’s ratings are predictive of those of a second rater, whereas G2 indicates the extent to which the average score provided by 2 raters could be used to predict the average scores provided by another pair of raters. The reliability of the CSR process can be examined in a more elaborate fashion due to the availability of a second variable (case). The intercase reliability for the ratings assigned to a single case (ie, the extent to which the ratings assigned to one case can be expected to correlate with those assigned to another case) was found to be .65. This reliability

Table 2. Summary of the Primary Assessors’ Ratings for the Components of the Onsite Assessmenta Component

Needs Minor Improvements

Needs Major Improvements 3%, n⫽3

Summary report

106

87%, n⫽92

10%, n⫽11

105

92%, n⫽97

8%, n⫽8

Record keeping

102

71%, n⫽72

23%, n⫽24

Billing practiceb

67

90%, n⫽60

9%, n⫽6

695

91%, n⫽634

7%, n⫽48

Portfolio Component CV

b

Satisfactory

Practice/facility issues

CSR process

a

n

n

Present

Absent

105

99%, n⫽104

1%, n⫽1

PISA

105

98%, n⫽103

2%, n⫽2

Professional development

105

96%, n⫽101

4%, n⫽4

Unacceptable

6%, n⫽6 1%, n⫽1 2%, n⫽13

CSR⫽chart-stimulated recall, CV⫽curriculum vitae, PISA⫽Professional Issues Self-Assessment. Dependent on the physical therapist’s work setting and not applicable to all physical therapists.

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Competence Assessment in Physical Therapy Table 3.

Table 4.

Table 5.

Interrater Reliability Coefficients for the Various Components of the Onsite Assessmenta

Inter-case Reliability for Varying Numbers of Charts Reviewed in the Chart-Stimulated Recall Process

Overall Test Reliability for the ChartStimulated Recall Process Expressed as a G Coefficienta as a Function of the Number of Charts and Raters (n⫽53)

Component Record keeping

n

G1

G2

50

.66

.79

Practice issues

53

.64

.78

Billing practices

31

.12

.22

PISA

53

.66

.80

CSR process (averaged across 6 charts)

53

.54

.70

Summary report

52

.74

.85

No. of Charts

G Coefficienta

1

.65

2

.79

3

.85

4

.88

5

.90

6

.92

a PISA⫽Professional Issues Self-Assessment, CSR⫽chart-stimulated recall, G1⫽the interrater reliability of the ratings assigned to physical therapists by a single rater, G2⫽the interrater reliability of the ratings assigned to physical therapists by averaging across 2 raters. No variability for curriculum vitae or professional development noted.

a

rose to .92 when the average rating, taken across 6 cases, was considered. The D-study revealed that the number of charts peer assessors were asked to review could be dropped to 2 or 3 while still achieving an acceptable inter-case reliability (G⬎.75) (Tab. 4).

sional educational program (r⬍.05 in all instances) (Tab. 6). The correlation between the final decision of the QM Committee and the mean summary report score was r⫽.50 (P⬍.01) (n⫽105). The univariate correlation between each pair of components is shown in Table 7. Using multiple regression analysis, record keeping was found to be the most significant contributor to both the QM Committee’s final decision and the assessors’ mean summary report. Table 8 presents the results of the regression analysis.

The overall test reliability (ie, generalizing across both raters and cases at the same time rather than considering each in isolation) was .48 for a single observation (one rater and one chart). This statistic indicates the extent to which the scores assigned by one rater to one chart is predictive of the scores assigned by another rater to a different chart. Table 5 illustrates the results of the D-study, which indicate the impact on overall test reliability of averaging across variable numbers of cases and raters. Objective 2: Relationships Between the QM Committee’s Final Decision and Other Components of the Onsite Assessment No significant relationships were identified between the final decision and the physical therapists’ age, years since graduation, or profesJuly 2010

The G coefficients refer to the extent to which the ratings assigned to physical therapists using an average of a number of cases can be used to predict the ratings assigned to the average of another number of cases. Although physical therapists had 6 charts reviewed in their Onsite Assessment, acceptable inter-case reliability (G⬎.75) was achieved as long as the ratings collected on at least 2 charts were averaged.

Discussion The reliability of an assessment tool addresses the amount of error, both random and systematic, inherent in any measurement, and it also reflects the ability of that tool to consistently discriminate among the individuals assessed.28 The interrater reliability of the various components of the Onsite Assessment ranged from fair to good, with the exception of the assessment of billing practices. These findings were similar to those reported for the peer-assessment program undertaken by the College of Physicians and Surgeons of Ontario, where a CSR process also was

No. of Charts

1 Rater

2 Raters

1

.48

.62

2

.58

.72

3

.62

.75

4

.65

.78

5

.66

.79

6

.67

.80

a

The G coefficients refer to the overall test reliability, which indicates the extent to which the ratings assigned to physical therapists by 1 or 2 raters on 1 or more charts predict the ratings assigned to another 1 or 2 raters and another 1 or more charts. That is, they indicate the amount of variance that can be attributed to physical therapists when both rater and case are allowed to add error to the measurement and when that measurement error is diluted to varying degrees by increasing or decreasing the number of observations across which a person can generate an average score.

used.9 Salvatori and colleagues14 had reported a higher interrater reliability of the CSR process in a sample of occupational therapists (ICC⫽.97). The lack of reliability for the billing practices component most likely arose because there was so little variability in performance (as shown in Tab. 2), which ultimately affects the ability of the tool to reliably discriminate among physical therapists. Although the reliability of the components is improved with additional raters, using one rater and a triangulation of methods across the Onsite Assessment in order to make a decision about competency (ie, considering the results across the various components) may be the most feasible manner in which to account for the moderate reliability of the individual components. The results of this study indicate that the assessors can reduce the number of charts reviewed with the physical therapist from 6 to 3 and still achieve acceptable reliability (inter-case ICC⫽.85). The high inter-case reli-

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Competence Assessment in Physical Therapy Table 6.

important to review that number in order to ensure that the physical therapist was meeting the documentation standards.

Relationships Among Demographic Factors and the Final Decision Expressed Using Spearman Correlation Coefficients Factor

Age

Years in Practice

Educationa

Final decision

⫺.09

⫺.09

.01

Age a b

.94

⫺.53

b

b

Education reported as diploma or baccalaureate degree. P⬍.01.

ability in this study was likely due to a number of factors. The candidates were free to choose their own charts in this study; therefore, they may have selected those that addressed patients with similar conditions, leading to little variation. Furthermore, the “halo effect” bias may come into play here, with the assessors being biased in the assessment of the charts encountered later in the CSR process by their perception of the charts presented earlier in the process.32 The inter-case reliability estimated in this study was higher than that identified in the study by Salvatori and colleagues,14 who found that a random sample of 11 charts was required to yield an overall reliability of .90. The charts for the CSR process were selected randomly in the study by Salvatori and colleagues, which may have given rise to a more heterogeneous sample of cases, thereby producing greater

variation in each occupational therapist’s performance.14 Asking the physical therapist to select the 6 to 8 charts for the Onsite Assessment (in contrast to having hospital personnel or the assessor select the charts) could raise the concern that he or she might select only the charts representing the provision of care meeting all the required standards. However, this does not appear to be the case, because in both the CSR process and the record-keeping evaluations, the assessors were able to reliably identify a range of performances within the sample. Therefore, the selection of charts by the physical therapist seems to be acceptable. Subsequent to this study, the number of charts required for review in the Onsite Assessment was reduced to 6, rather than 6 to 8. The number of charts reviewed was not reduced to a number less than 6 because the QM Committee felt it was

None of the demographic factors examined in this study (ie, registrants’ age, time since graduation, or professional education) were found to be associated with registrants’ performance. Similar findings (ie, no significant correlation between performance and time since graduation) were reported in samples of both Canadian and internationally educated physical therapists beyond their graduation year who completed the written component of the Canadian Physiotherapy Competency Examination.33 These findings stand in contrast to the significant inverse relationship between competence and age or time since graduation identified among physicians9 –11 and pharmacists.12 Age and time since graduation were highly correlated for obvious reasons. The education factor is highly correlated with both of these factors as a result of the historical context, where the entry-level diploma program was replaced by the baccalaureate program in Canada. Further study to investigate the factors associated with poor performance on the Onsite Assessment, which may be indicative of

Table 7. Univariate Correlations Among the Assessment Components, the Summary Report Mean, and the Quality Management Committee’s Final Decisiona Final Decision Summary report mean

.50

Practice issues mean

.19

Billing mean Record-keeping mean

a b

Summary Report

b

⫺.18 .54b

Practice Issues

Billing

Record Keeping

Professional Development

PISA

CV

. .46b ⫺.08 .57b

⫺.01 .32b

⫺.13

Professional development

.09

⫺.06

⫺.04

⫺.12

.05

PISA

.19

⫺.04

⫺.03

⫺.09

⫺.08

.70b

CV

.19

⫺.04

⫺.03

⫺.09

⫺.08

.70b

1.00b

CSR mean

.48b

.16

⫺.01

.04

.07

.29b

.40b

.07

PISA⫽Professional Issues Self-Assessment, CV⫽curriculum vitae, CSR⫽chart-stimulated recall. P⬍.01.

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Competence Assessment in Physical Therapy failure to comply with certain standards of practice, is warranted.

Table 8. Relationships Among Onsite Assessment Components Explored Using Multiple Linear Regressiona

There was a moderate correlation between the QM Committee’s final decision and the summary report from the assessor (r⫽.50, P⬍.01). Although a stronger correlation between these 2 ratings might have been anticipated, this finding could be attributed to several factors. It could be that the assessors were not comfortable in assigning scores lower than “satisfactory.” Norcini34 has suggested that when the stakes are high, as they would be in the Onsite Assessment, peers can be reluctant to provide lower ratings. As well, it could be that the scoring guidelines were unclear or misinterpreted by the assessors, which could be the case because this study was undertaken using the results from the first months of the new program. The majority of physical therapists in this sample (88%) were deemed to be providing safe and competent care, as determined through the document reviews and discussions with the physical therapists. Although this finding speaks well of the physical therapists involved, of greater concern are those who do not meet the required standards. Eleven percent of therapists (n⫽12) were required to engage in a remediation process. This finding is similar to those in peer-assessment reviews of physicians, where 10% to 12% have been identified as demonstrating serious difficulties9 –11 and 14% of pharmacists in the same Canadian jurisdiction.12 These findings alone indicate the importance of instituting a formal program such as the Onsite Assessment to identify those physical therapists whose practice falls below acceptable standards in order to protect the public from harm. The majority of remediation processes required of the therapists were selfdirected, suggesting that the issues were not major. In only a few cases July 2010

Dependent variable: final decision,b R2ⴝ.55 (nⴝ103) Standardized Coefficient Beta

Independent Variable

P

Summary report mean

.22

.04

Facility and practice issues mean

.05

.50

Billing mean Record-keeping mean CV

⫺.11

.12

.35

.01

Excluded

PISA

.30

Professional development CSR mean

.01

⫺.11

.28

.22

.01

Dependent variable: summary reportc mean score, R2ⴝ.56 Standardized Coefficient Beta

Independent Variable Practice issues mean

.23

Billing mean Record-keeping mean CV

CSR mean

c

.50

.61

.01

.10

Professional development

b

⫺.05

Excluded

PISA

a

P .01

.30

⫺.15

.13

.07

.43

CV⫽curriculum vitae, PISA⫽Professional Issues Self-Assessment, CSR⫽chart-stimulated recall. Made by the Quality Management Committee. Made by the peer assessor.

(n⫽3) was the remediation directed by the QM Committee, indicating a more serious concern. All remediations were followed by a reassessment to ensure the appropriate standards of practice had been met. The results of the regression analyses suggest that the physical therapists’ performance in record keeping predominantly informed the ratings of both the peer assessors (ie, summary report) and the QM Committee (ie, final decision). This was the component of the Onsite Assessment with the poorest performance, with only 71% of the physical therapists viewed by the peer assessor as demonstrating “acceptable” practices. It is not surprising, therefore, that this component appeared as the most predictive independent variable in

both regression analyses, as it was the component demonstrating the greatest variability. The incidence of successful charting procedures is similar to that in a sample of Quebec physicians surveyed through the Colle`ge des Me´dicins du Que´bec, where 75% were judged to have good record-keeping practices.35 Reported record-keeping deficiencies have been related to the omission of important details, poor organization, and illegibility.36 There is evidence that remediation directed by a regulatory agency can result in improved clinical practice, including improved record keeping.37 Little is known about the relationship between submitting a PISA and adherence to professional standards, but it seems likely that the same characteristics that lead a person to keep careful

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Competence Assessment in Physical Therapy records also may result in diligence with respect to completing this sort of administrative task. The predictive nature of the CSR process adds to the promise inherent in previously published research into the psychometric properties of this activity from other professions.14 Van der Vleuten’s model of utility21,22 has informed our review of the CPO Onsite Assessment. Because this is a summative assessment, with consequences related to therapists’ ability to maintain their license to practice, great weight was placed upon the reliability of the assessment. The results of this study indicate that defensible summative decisions can be made using the current process and that the number of charts required for review can be reduced. The content validity of the process was defined through the comprehensive development process, which included pilot testing. Feedback is requested from physical therapists following the Onsite Assessment, which addresses some aspects of the acceptability and educational impact of the process. Although the costs of conducting such a program are quite high, averaging $525.00 (Canadian) per physical therapist assessment undertaken by one assessor (which includes the assessor’s travel costs),38 the feasibility of this process has been determined to be acceptable by the CPO. This model may be useful to others (eg, other regulatory agencies, physical therapy managers or educators) who develop and use competence assessment tools or programs. There are several limitations to this study. Although the sample size for this study was small, it was a random sample from the largest jurisdiction in Canada and, as such, offers us the first evidence regarding the continuing competence of Canadian physical therapists. Additionally, the Onsite Assessment does not include 1036

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observation of the therapist while he or she is providing patient care or communicating with others (eg, patients, families, other health care professionals in a variety of contexts). Rethans and colleagues39 have identified the importance of addressing system-related factors (eg, policies and guidelines in the facility, access to other health care professionals) and individual characteristics (eg, mental health, relationships with others) when assessing clinical competence. The Onsite Assessment offers the assessor an opportunity to directly interact with the physical therapist and to evaluate his or her practice in the context of the work environment through document review and discussion. The Onsite Assessment, with the personal interaction between the assessors and the examinees in their workplace, appears to be a feasible process that can offer a comprehensive view of the physical therapist’s continuing competence. Further validity testing, however, is needed before these conclusions can be stated with absolute confidence. Subsequent research related to the Onsite Assessment could further address the validity of the process, potentially using a global rating scale completed by peer14 or multi-source feedback questionnaires.40,41 A study is under way to re-examine the reliability and validity of the Onsite Assessment (now called the Practice Assessment) using methods similar to those reported here, as it has been in operation for several years. Furthermore, the educational impact of the Onsite Assessment could be interesting to study because the registrants receive both formative and summative feedback through the process. An exploration of how the registrants use the feedback (ie, whether it alters their practice or influences the selection of continuing education events) might be interesting to undertake.

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Conclusion This is the first publication to report the results of peer assessment of continuing competence in a sample of physical therapists. The majority of the physical therapists assessed in the Onsite Assessment were considered to be providing competent care and adhering to professional standards of practice. This study provides important information about the psychometric properties of the components of the Onsite Assessment. When only one assessor was used, the reliability of the various components of the Onsite Assessment ranged from fair to good. However, using triangulation of results from various tests and the summary report that comprise the Onsite Assessment to inform the final decision should enhance the validity of the process. The findings indicate that the number of charts reviewed in the CSR process can potentially be reduced. Unlike similar studies with physicians and pharmacists, no evidence of a decline in competency associated with increasing age or time since graduation was demonstrated in this sample. Further research to identify factors associated with physical therapists’ failure to comply with the required standards of practice is indicated. The results of this study can provide valuable information to other physical therapy regulatory agencies or managers considering similar continuing competency assessment programs. All authors provided concept/idea/research design. Dr Miller and Dr Eva provided writing and data analysis. Dr Nayer provided data collection, participants, and institutional liaisons. Dr Miller and Dr Nayer provided project management. Dr Nayer and Dr Eva provided consultation (including review of manuscript before submission). Ethical approval for this study, which was conducted as part of Dr Miller’s PhD thesis, was secured from the Faculty of Health Sciences’s Research Ethics Board at McMaster University.

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Competence Assessment in Physical Therapy A podium presentation of this research was given at the 15th International Congress of the World Confederation for Physical Therapy; June 6, 2007; Vancouver, British Columbia, Canada. This research was funded by a Strategic Training Fellowship in Rehabilitation Research to Dr Miller from the Institute of Musculoskeletal Health and Arthritis of the Canadian Institutes of Health Research. This article was submitted May 6, 2008, and was accepted March 18, 2010. DOI: 10.2522/ptj.20080137

References 1 Epstein RM, Hundert E. Defining and assessing professional competence. JAMA. 2002;287:226 –235. 2 Lane M. The case for continuing competency. PT Magazine. 1999;7(5):48 –56. 3 The Federation of State Boards of Physical Therapy. Standards of competence. Available at: http://www.fsbpt.org/download/ StandardsOfCompetence2006_10.pdf. Revised October 19, 2006. Accessed September 8, 2008. 4 College of Physiotherapists of Ontario. Standards for Professional Continuing Competence. Available at: http://www. collegept.org/Physiotherapists/College %20Documents/Registrants%20Guide/ StandardsforPractice. Accessed April 7, 2010. 5 Swisher LL, Page CG. Professionalism in Physical Therapy: History, Practice, and Development. St Louis, MO: Elsevier Saunders; 2005. 6 Miller PA. Self-assessment: the disconnect between research and rhetoric. Physiother Can. 2008;60:117–124. 7 Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 suppl):S46 –S53. 8 Regehr G, Eva KW. Self-assessment, selfdirection, and the self-regulating professional. Clin Orthop Relat Res. 2006;449: 34 –38. 9 Norman GR, Davis DA, Lamb S, et al. Competency assessment of primary care physicians as part of a peer review program. JAMA. 1993;270:1046 –1051. 10 Cunnington JPW, Hanna E, Turnbull J, et al. Defensible assessment of the competency of the practicing physician. Acad Med. 1997;72:9 –12. 11 McAuley RG, Henderson HW. Results of the peer assessment program of the College of Physicians and Surgeons of Ontario. Can Med Assoc J. 1984;131: 557–561. 12 Austin Z, Marini A, Croteau D, Violato C. Assessment of pharmacists’ patient care competencies: validity evidence from Ontario (Canada)’s Quality Assurance and Peer Review Process. Pharm Educ. 2004; 4:23–32.

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13 Regulated Health Professionals Act (RHPA), 1991. Available at: http://www. collegept.org/Physiotherapists/College% 20Documents/Registrants%20Guide/ RegistrantsGuide. Accessed on April 7, 2010. 14 Salvatori P, Bapiste S, Ward M. Development of a tool to measure clinical competence in occupational therapy: a pilot study? Can J Occup Ther. 2000;67:51– 60. 15 Salvatori P, Simonavivius N, Moore J, et al. Meeting the challenge of assessing clinical competence of occupational therapists within a program management environment. Can J Occup Ther. 2008;75:51– 60. 16 College of Physiotherapists of Ontario. Practice Assessment. Available at: http://www.collegept.org/Physiotherapists/ Quality%20Management/QualityManage ment. Accessed April 7, 2010. 17 College of Physiotherapists of Ontario. Standards for Practice for Physiotherapists. Available at http://www.collegept. org/Physiotherapists/College%20 Documents/Registrants%20Guide/ StandardsforPractice. Accessed April 7, 2010. 18 College of Physiotherapists of Ontario. Code of Ethics. Available at: http://www. collegept.org/Physiotherapists/College%20 Documents/Registrants%20Guide/Standards forPractice. Accessed September 15, 2008. 19 College of Physiotherapists of Ontario. Quality Management. Available at: http:// www.collegept.org/Physiotherapists/Quality %20Management/QualityManagement. Accessed October 15, 2007. 20 College of Physiotherapists of Ontario. Practice assessment forms. Available at: http://www.collegept.org/Physiotherapists/ Quality%20Management/Practice%20 Assessment/PracticeAssessmentProcess. Accessed November 11, 2009. 21 van der Vleuten CPM. The assessment of professional competence: developments, research, and practical implications. Adv Health Sci Educ. 1996;1:41– 67. 22 van der Vleuten CPM, Schuwirth LWT. Assessing professional competence: from methods to programmes. Med Educ. 2005; 39:309 –317. 23 Accreditation Council for Canadian Physiotherapy Academic Programs, Canadian Alliance of Physiotherapy Regulators, Canadian Physiotherapy Association, Canadian Universities Physical Therapy Academic Council. Essential Competency Profile for Physiotherapists in Canada. Ottawa, Ontario, Canada; 2004. 24 Physiotherapy Act, 1991. Ontario Regulation 532/98. Available at: http://www. e-laws.gov.on.ca/html/regs/english/elaws_ regs_980532_e.htm. Accessed September 15, 2008. 25 College of Physiotherapists of Ontario. Practice Assessment Pilot Test: Report 2006. Available at http://www.collegept. org/Physiotherapists/Quality%20Manage ment/Quality%20Management%20 Documents/QualityManagementDocu ments. Accessed April 7, 2010.

26 College of Physiotherapists of Ontario. Guide to the Standard for Professional Practice: Performing Controlled Acts. Available at: http://www.collegept.org/ Physiotherapists/College%20Documents/ Registrants%20Guide/RegistrantsGuide. Accessed April 7, 2010. 27 American Physical Therapy Association. Position paper: Professional Development, Lifelong Learning, and Continued Competence in Physical Therapy. HOD P05– 07–14 –14. Available at: http:// www.apta.org/AM/Template.cfm?Section⫽ Policies_and_Bylaws1&CONTENTID⫽ 41705&TEMPLATE⫽/CM/ContentDisplay. cfm. Accessed October 9, 2009. 28 Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 3rd ed. New York, NY: Oxford University Press; 2003. 29 Shavelson RJ, Webb NM, Rowley GL. Generalizability theory. Am Psychol. 1989;44: 922–932. 30 Crossley J, Davies H, Humphris G, Jolly B. Generalisability: a key to unlock professional assessment. Med Educ. 2002;36: 972–978. 31 Carifio J, Perla R. Resolving the 50-year debate around using and misusing Likert scales. Med Educ. 2008;42:1150 –1152. 32 Thorndike EL. A constant error in psychological ratings. J Appl Psychol. 1920;4: 25–29. 33 Miller PA, Cooper MA, Eva KW. Factors predicting competence as assessed with the written component of the Canadian Physiotherapy Competency Examination. Physiother Theory Pract. 2010;26:12–21. 34 Norcini JJ. Peer assessment of competence. Med Educ. 2003;37:539 –543. 35 Goulet F, Jacques A, Gagnon R, et al. Performance assessment: family physicians in Montreal meet the mark! Can Fam Physician. 2002;48:1337–1344. 36 Caulford PG, Lamb SB, Kaigas TB, et al. Physician incompetence: specific problems and predictors. Acad Med. 1994; 69(10 suppl):S16 –S18. 37 Goulet F, Gagnon R, Gingras ME. Influence of remedial professional development programs for poorly performing physicians. J Contin Educ Health Prof. 2007;27:42– 48. 38 Nayer, M. Quality Management Program Evaluation Report. Toronto, Ontario, Canada: College of Physiotherapists of Ontario; 2003:397. 39 Rethans JJ, Norcini JJ, Baron-Maldonada M, et al. The relationship between competence and performance: implications for assessing practice performance. Med Educ. 2002;36:901–909. 40 Lockyer JM. Multisource feedback in the assessment of physician competencies. J Contin Educ Health Prof. 2003;23:4 –12. 41 Lockyer JM, Violato C, Fidler H. The assessment of emergency physicians by a regulatory authority. Acad Emerg Med. 2006;13:1296 –1303.

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Competence Assessment in Physical Therapy Appendix 1. Components of the Onsite Assessment Component

Mandatory?

Description

Professional portfolio review

Yes

Three sections were expected: (1) a curriculum vitae, (2) evidence of ongoing learning, and (3) a completed Professional Issues Self-Assessment questionnaire that asked registrants to self-assess their knowledge about College of Physiotherapists of Ontario standards.

Facility and practice issues evaluation

Yes

Included a walkabout survey of the registrant’s workplace and a discussion regarding practice, which addressed a range of activities such as the implementation of cleaning and infection control procedures, the process for obtaining informed consent, the performance of controlled acts, and the supervision of support personnel.

Record-keeping evaluation

Yes, 6–8 records

Addressed the compliance with documentation regulations such as the presence of signatures, dates, identification of the patient, completeness of the file, storage and disposal of records, and so on through document review and subsequent discussion with the registrant.

Chart-stimulated recall process

Yes, 6–8 records

Involved the use of a script of open-ended questions to discuss the care of patients, with reference to the documentation in the chart. It “combines the benefits of a personal interview and chart audit.”14(p53)

Billing practices evaluation

No, only for registrants for whom billing was part of their work setting requirements

Involved a discussion of items related to reimbursement for services such as fee schedules, how fees are set, and the monitoring of billing for support personnel.

Appendix 2. Description of the Possible Outcomes of the Onsite Assessment

Completed successfully: Registrants who have met the standards receive a letter stating they have completed the process successfully. There is no further follow-up from the College of Physiotherapists of Ontario (CPO). Completed with recommendations: The Quality Management (QM) Committee may determine that a physical therapist has met the standards, but may make some recommendations to registrants. An example might be to improve the charting details on the modalities or exercises they are including in their treatment plan. Self-directed remediation required: In some instances, the QM Committee may determine that some improvements are required, but they are of a nature such that the physical therapist can make the changes independently. The physical therapist may be asked to submit a learning plan with evidence of having carried out the plan. This type of remediation is generally followed up with a reassessment to confirm that the changes have been made. QM Committee-directed remediation required: The QM Committee has determined that some improvements are required and have dictated the terms of the remediation. For example, this might include time with a remediator. The remediator may assist with creating a learning plan and providing support during the completion of the learning activities. The remediation may include specifics such as meeting with a remediator monthly, reviewing a specified number of patient charts to ensure compliance with CPO standards, observing an assessment or treatment of a patient, or other activities. The QM Committee selects the activities that it deems would be helpful in assisting the therapist to meet CPO standards. Reassessment required: A second reassessment is undertaken to gather missing information to enable the QM Committee to make its decision. In such cases, the QM Committee may require a reassessment by a second assessor, who generally is not told that this is a reassessment to ensure an unbiased process.

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Focus on the ICF Using a Case Report of a Patient With Spinal Cord Injury to Illustrate the Application of the International Classification of Functioning, Disability and Health During Multidisciplinary Patient Management Alexandra Rauch, Reuben Escorpizo, Daniel L. Riddle, Inge Eriks-Hoogland, Gerold Stucki, Alarcos Cieza

Background and Purpose. Physical therapists require a comprehensive assessment of a patient’s functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability and Health (ICF) is the universally accepted conceptual model for the description of functioning. Documentation tools have been developed based on ICF Core Sets to be used in multidisciplinary rehabilitation management and specifically by physical therapists. The purposes of this case report are: (1) to apply ICF-based documentation tools to the care of a patient with spinal cord injury and (2) to illustrate the use of ICF-based documentation tools during multidisciplinary patient management.

Case Description. The patient was a 22-year-old man with tetraplegia (C2 level) who was 5 months postinjury. The report describes the integration of the ICF-based documentation tools into the patient’s examination, evaluation, prognosis, diagnosis, and intervention while he participated in a multidisciplinary rehabilitation program for 2 months.

Outcomes. The patient’s comprehensive functioning status at the beginning of the program, the rehabilitation goals, the intervention plan, and his improvements in functioning following rehabilitation and the according goal achievement were illustrated with physical therapy–specific and multidisciplinary ICF-based documentation tools.

Discussion. This case report illustrates how the ICF-based documentation template for physical therapists summarizes all relevant information to aid the physical therapist’s patient management and how ICF-based documentation tools for multidisciplinary care complement one another and thus can be used to enhance multidisciplinary patient management. In addition, the ICF assists in clarifying clinician roles as part of a multidisciplinary team. The case report demonstrates that the ICF can be a viable framework both for physical therapy and multidisciplinary management and for clinical documentation.

A. Rauch, PT, BSc, is Project Leader, Swiss Paraplegic Research, Nottwil, Switzerland, and Project Scientist, ICF Research Branch, WHO CC FIC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Science (IHRS), Ludwig-Maximilian University, Munich, Germany. R. Escorpizo, PT, DPT, MSc, is Research Scientist, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO CC FIC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Science (IHRS), Ludwig-Maximilian University, Munich, Germany. D.L. Riddle, PT, PhD, FAPTA, is Otto D. Payton Professor, Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia. I. Eriks-Hoogland, MD, is Medical Officer, Swiss Paraplegic Research, Nottwil, Switzerland. G. Stucki, MD, MS, is Professor and Chair, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; Director, Swiss Paraplegic Research, Guido A. Za¨ch Strasse 4, CH-6207 Nottwil, Switzerland; and Director, ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. Address all correspondence to Dr Stucki at: [email protected]. Author information continues on next page. Post a Rapid Response to this article at: ptjournal.apta.org

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Application of the ICF in Multidisciplinary Patient Management A. Cieza, PhD, MPH, is Senior Scientist, Institute for Health and Rehabilitation Sciences (IHRS), Ludwig-Maximilian University, Munich, Germany; Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. [Rauch A, Escorpizo R, Riddle DL, et al. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther. 2010;90:1039 –1052.] © 2010 American Physical Therapy Association

I

n many clinical settings, physical therapy often is one critical part of multidisciplinary rehabilitation programs that aim to enable people with health conditions to achieve and maintain optimal functioning and to encourage full participation of individuals in all aspects of life in their environment.1,2 Spinal cord injury (SCI) is an example of a condition in which patients are faced with a multitude of health-related problems with respect to body functions (physiological functions of body systems) and body structures (anatomical parts of the body) and to activities (execution of tasks or actions) and participation (involvement in life situations), and environmental factors (physical, social, and attitudinal environment in which people live and conduct their life)3 often play a key role. When multiple systems are affected, as they are in SCI, multidisciplinary approaches are important for optimal care.4 To address multiple problems, a comprehensive description of a patient’s functioning status is an essential element of sound patient management.5 The International Classification of Functioning, Disability and Health

Available With This Article at ptjournal.apta.org • eTable 1: Physical Therapist Documentation Template: Complete Version • eTable 2: International Classification of Functioning, Disability and Health (ICF) Intervention Table: Complete Version • Discussion Podcast: See the PTJ Web site for participants. • Audio Abstracts Podcast This article was published ahead of print on May 27, 2010, at ptjournal.apta.org.

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(ICF)6 is the universally accepted conceptual model for the description of functioning. The ICF refers to functioning as an umbrella term for body functions and body structures and for activities and participation. Functioning and disability are considered to be the result of the interaction between a health condition and personal and environmental factors. As a classification system, the ICF provides a hierarchical organization of “descriptors” in the form of ICF categories. Thus, the ICF framework offers physical therapists and other rehabilitation professionals a common understanding and a standardized language to describe functioning.7 With the endorsement of the ICF by the American Physical Therapy Association,8 physical therapists are now faced with the challenge of concretely translating the use of ICF in their daily clinical practice. To address the needs of users, ICF-based practical tools, including the ICF Core Sets,9,10 have been developed. The ICF Core Sets provide a list of ICF categories applicable and relevant to specific health conditions. Although Brief ICF Core Sets are developed for single encounters, Comprehensive ICF Core Sets are intended for use in multidisciplinary settings.11 The ICF Core Sets serve as practical tools for the documentation and as a reference standard for the reporting of functioning.11 To report the extent of problems in specific ICF categories, ICF qualifiers can be used as a rating scale from 0 to 4, which includes the equivalent percentage values as a reference6: 0—no problem (none, absent, negligible) 0%– 4% 1—mild problem 5%–24%

(slight,

2—moderate problem fair) 25%– 49%

low)

(medium,

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Application of the ICF in Multidisciplinary Patient Management 3—severe problem (high, extreme) 50%–95% 4—complete 96%–100%

problem

(total)

Supplementary to the ICF Core Sets, so-called ICF-based documentation tools have been developed to be used in multidisciplinary rehabilitation management.12 In addition, an ICF-based documentation template is suggested by Escorpizo et al13 (see companion perspective article in this issue) to be used specifically by physical therapists. This template is based on the Guide to Physical Therapist Practice14 (herein referred to as the Guide), the elements of which consist of examination and evaluation of the patient’s level of functioning, a description of a diagnosis and prognosis, the generation of a plan of care, intervention, and reexamination. The ICF-based documentation tools for multidisciplinary management and the documentation template for physical therapists can be used to complement each other, to illustrate a patient’s functioning status, and to chronicle patient management (Fig. 1). The purposes of this case report are: (1) to apply the ICF-based documentation tools for physical therapy and multidisciplinary teams to the care of a patient with SCI and (2) to illustrate the use of ICF-based documentation tools during the patient’s care. These documentation tools were integrated with the patient management elements described in the Guide. The patient had an incomplete cervical SCI, and our description of the multidisciplinary care begins 5 months postinjury.

Patient History The patient was a 22-year-old man who had started his career as an online graphic designer. A diving accident resulted in a type II dens fracture of the second cervical vertebra July 2010

Figure 1. Overview of the use of International Classification of Functioning, Disability and Health (ICF)-based documentation tools in patient management.

(C2). He was treated at a local hospital and transported to an SCI center 2 days later. He was admitted to the intensive care unit and initially diagnosed with tetraplegia below C2, classified as AIS (American Spinal Injury Association [ASIA] Impairment Scale15) grade A (“no motor or sensory function is preserved below the level of injury”). Three days postinjury, surgery was performed to stabilize the fracture. A stiff collar was prescribed for the first 6 weeks following the surgery. After the surgery, the patient was admitted to the early postacute inpatient unit of the SCI center, where a multidisciplinary rehabilitation program was initiated. In the first 2 weeks, the patient was completely dependent. He required the use of an artificial ventilator 24 hours a day, received only intravenous nutrition, and was able to move only his eyes and mouth. After 6 weeks, his movement-related functions had improved, and he required artificial ventilation only at night. Over the next several weeks, the patient’s neurological and overall func-

tioning continued to improve. Upright positioning and graduated training activities to improve gait patterns could be initiated as tolerated by the patient. Five months after the injury, he was able to stand and to take few steps in the parallel bars. Furthermore, the patient achieved a degree of independence in the areas of self-care, respiration and sphincter management, and mobility. This case report was undertaken 5 months following injury and 2 months before the planned discharge. At this time point, a new examination became necessary to adapt and coordinate the plan of care to account for the patient’s improved functioning status that had occurred since the injury. The new examination data were used to coordinate and revise care for the remainder of the patient’s stay in the rehabilitation center.

Examination The Comprehensive ICF Core Set for SCI in the early postacute context16 was used as the basis to guide the examination. For the description of

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a

Yes

No

b770 Gait pattern functions

Body Structures

Position of backrest, size of cushion not optimal

10 steps with support by parallel bars or forearm crutches

Needs to hold on to something due to lack of power and coordination

STG1

STG1

STG1

STG1

STG1

Intervention Target, Related to STG/LTG Number?

Will be optimized

Will walk up to 10 m without support

Standing without support

Walking without forearm crutches for moderate distance (up to 100 m)

Related to neurological recovery Training might increase muscle power functions

Prognosis (Only for Intervention Targets)

The patient will be referred to physical therapy and occupational therapy outpatient rehabilitation programs

Refer to companion perspective article by Escorpizo et al13 in this issue. AIS⫽American Spinal Injury Association [ASIA] Impairment Scale.14

Other Notes:

Discharge Plan:

Negative

Influence

Inspection of wheelchair fit

Measurement of walking distance

Observation

Hyper-extension of the knee joints Abnormal shifting of the upper body Lack of arm swinging Requires forearm crutches for safety reasons

12.6/14.3(left/right)

Jamar dynamometer17 Fist closing (kg) Observational gait analysis

M. gluteus maximus: 4/4 (left/right) M. gluteus medius: 3/3 M. quadriceps femoris: 5/5 M. tibialis anterior: 5/5 M. triceps surae: 3/3

Test Value

Manual muscle testing15

Test

Examination

5 Months Post-SCI

Assigned to occupational therapist

Gait training/outdoor training

Repetitive training of transfers

Gait training inside and outside of the parallel bars

Strength training with equipment

Physical Therapy Sessions Will Be Provided 1 or 2 Times Daily

Intervention ⴙ Frequency

Diagnosis: Spinal cord injury (SCI), AIS grade C

Main problems in the area of mobility according to abnormal movement caused by neurological impairment decreased exercise tolerance Optimistic prognosis due to expected neurological recovery and facilitating environmental and personal factors

X

Evaluation and Overall Prognosis:

X

Acceptance of disease

Positive

Goal orientation/motivation

Personal Factors (Pf)

e120 Products and technology for personal indoor and outdoor mobility and transportation

Yes

Yes

d4500 Walking short distances

Environmental Factors

Yes

d4104 Standing

Activities and Participation

Yes

Need to Examine?

b7304 Power of muscles of all limbs

Body Functions

ICF Categories– Intervention Targets

Date

Patient’s Goal: Independent living in the community Long-term goal (LTG): Resumption of leisure activities Short-term goal (STG): 1: Locomotion 2: Carrying, moving, and handling objects

Physical Therapist Documentation Templatea: Selected Codes as Examples

Table 1.

Optimal fit

Able to walk up to 600 m without device

No support necessary anymore

Able to walk up to 600 m without abnormal gait patterns

M. gluteus maximus: 4/4 M. gluteus medius: 3/3 M. quadriceps femoris: 5/5 M. tibialis anterior: 5/5 M. triceps surae: 4/4 20.4/20.8

Retest Value (Only for Intervention Targets)

Re-examination

Yes

Yes

Yes

Yes

Yes

Goal Achieved?

7 Months Post-SCI

Application of the ICF in Multidisciplinary Patient Management

July 2010

Application of the ICF in Multidisciplinary Patient Management the patient’s current functioning status, the responsibility to examine specific ICF categories was distributed among the physical therapist and the other rehabilitation team members. Problems experienced by the patient were assessed via interview. Afterward, tests were performed to examine each ICF category. The documentation template for physical therapists was used to document the specific tests, examinations, or observations performed by the physical therapist (Tab. 1) (see eTab. 1, available at ptjournal. apta.org, for the complete version of the physical therapist documentation template). In the ICF component of body functions and body structures, the physical therapist identified problems such as reduced “b265 Touch functions” and “b270 Sensory functions related to temperature and other stimuli.” The patient also had reduced “b7304 Power of muscles of all limbs” and increased “b7353 Tone of muscles of lower half of the body,” indicating spasticity (hypertonicity). The patient’s “b455 Exercise tolerance” was decreased and his “b440 Respiration functions” showed reduced breathing patterns. Impairments in “b280 Sensation of pain” and “b720 Mobility in joint functions” in the right shoulder also were found; both are known as frequent problems in patients following SCI.17,18 The observation of his “b770 Gait patterns” showed noticeable problems typical for a lack in muscle power. Together with the problematic “b755 Involuntary movement reaction functions” and “b760 Control of voluntary movements,” the latter impairments in body functions were considered to increase the risk for falls.19 Under the ICF component of activities and participation, the physical therapist identified limitations in all aspects of walking, such as “d4501 July 2010

Walking long distances,” “d4502 Walking on different surfaces,” and “d4503 Walking around obstacles.” Accordingly, “d455 Moving around,” presented as difficulties climbing stairs, and “d460 Moving around in different locations” were reflected in his limitations to ambulate in different environments. Due to these limitations, he still required the use of a wheelchair, particularly for long distances. The patient was able to propel the wheelchair and handle the forearm crutches, as captured by the ICF category “d465 Moving around using equipment.” Although the patient participated in playing table tennis in a supported standing position and some recreational events, his former activities such as riding a bicycle and jogging under category “d920 Recreation and leisure” were completely restricted. As part of multidisciplinary care, other health care professionals also examined the patient and documented their results in their specific documentation forms. Evaluation The results of the examinations were evaluated, taking into account problems that were indicated by the patient and identified by each team member after performing specific examination procedures. The evaluation included both the analysis of the test results and the rating of the extent of the problem in each ICF category using the ICF qualifiers. The analyses of the results of the physical therapist’s examination were considered to be related to abnormal “movement.” The patient demonstrated clear limitations or restrictions in mobility, particularly with those activities that require lowerextremity function such as transferring, walking, moving around, and driving. These limitations in mobility were considered to be related to neurological impairments (leading to reduced muscle power, touch, and movement functions, among other impairments) and presumably were

due to his impaired respiratory functions and sedentary lifestyle, with limited activity for 5 months since the accident that led to reduced exercise tolerance. These mobility problems appeared to further affect the patient’s abilities in recreation and leisure, mainly in sporting activities. Afterward, each ICF category was rated by the responsible team member with an ICF qualifier to provide information to the rehabilitation team and to allow the evaluation of the patient’s comprehensive functioning state from a multidisciplinary perspective. The examination result served as the basis for this rating to define this evaluation value. Rating all ICF categories allowed the compilation of the patient’s comprehensive functioning state within the ICF Categorical Profile.12 This profile served as the central information source for the rehabilitation team toward planning the intervention (Fig. 2). In addition to the physical therapist’s examination and evaluation, the following information was provided by other team members and was discussed based on the patient’s ICF Categorical Profile. The occupational therapist reported moderate limitations in “d440 Fine hand functions” and “d430 Lifting and carrying objects” due to impaired sensory and muscle power functions. The category “d540 Dressing” was rated as having a mild problem because it took him a longer than normal to dress himself. The nurse reported mild impairments in “b525 Defecation functions”; however, with regard to “d530 Toileting” as an activity, the patient was reported to be independent. The vocational counselor rated category “d850 Remunerative employment” as having moderate problems. At the time of the examination, the patient had already started working part-time as a

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Application of the ICF in Multidisciplinary Patient Management

Figure 2. International Classification of Functioning, Disability and Health (ICF) Categorical Profile.12 The list includes all ICF categories from the Brief ICF Core Set for spinal cord injury in the early postacute context (marked in bold letters) and additional ICF categories from the Comprehensive ICF Core Set for spinal cord injury in the early postacute context examined by the physical therapist and other health care professionals. Asterisk (*) indicates all ICF categories examined by the physical therapist. †ICF qualifiers ranged from 0 (no problem) to 4 (complete problem) in the components of body functions, body structures, and activity and participation and from 4 (complete barrier) to ⫹4 (complete facilitator) in the environmental factors. In personal factors, the positive, neutral, or negative influence on the individual’s functioning is marked.

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Application of the ICF in Multidisciplinary Patient Management

Figure 2. Continued

graphic designer for his former employer but within the rehabilitation setting in the center. Information regarding environmental factors was gathered from all health care professionals involved in the patient’s care. The patient’s family (“e310 Immediate family”) and the rehabilitation team (“e355 Health professionals”) were rated as being supportive. The patient had already received “e1201 Assistive products and technology for personal indoor and outdoor mobility and transportation,” including a wheelchair and forearm crutches, which served as environmental facilitators. At the personal factors level, ambition and clearly defined personal goals were identified. Based on the patient’s comments and his attitude during rehabilitation, he was judged by the rehabilitation team as somebody who has accepted his current situation. July 2010

The evaluation from the multidisciplinary perspective confirmed the main problem of the patient in the area of mobility. Furthermore, his vocational situation was reported as less problematic because his work demands did not require extensive amounts of movement. The environmental factors were all evaluated as facilitators and thus were evaluated to contribute to the patient’s recovery. Diagnosis The ICF Assessment Sheet12 (Fig. 3) supported the diagnostic process, based on a clinical reasoning process. This form provides an overview of the functioning state from both the patient-identified problems using the patient’s words gathered from the routine interview that was guided by the ICF components (upper part of the sheet) and the health professional–identified problems described in the ICF codes (lower part

of the sheet). With this comprehensive overview, which includes all components of functioning, the identification of the relationship between problems and identified causes was facilitated and was easily illustrated. For example, the hypothesized causes for the patient’s experienced problems in locomotion (marked in the upper part of the sheet) could be identified from the list of problems identified by the examinations of the health care professionals (eg, “b455.1 Exercise tolerance functions” and “b770.3 Gait pattern functions”). Afterward, these relationships were illustrated with connecting lines. Based on the findings, the patient’s neurological health state was diagnosed as AIS grade C (incomplete SCI, “motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle

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Figure 3. International Classification of Functioning, Disability and Health (ICF) Assessment Sheet.12 The upper part of the ICF Assessment Sheet illustrates the patient‘s perspective of functioning in all components of the ICF. The lower part the evaluation of results from the health care professional’s examinations. Each ICF category is rated within an ICF qualifier from 0 (no problem) to 4 (complete problem) (number behind the dot). In “Environmental Factors,” a ⫹ denotes a facilitator. The main problems related to locomotion, experienced by the patient are highlighted within the cycle in the upper part. Causes for these limitations were identified by the health care professionals and marked within a connecting line and later defined as intervention targets.

grade less than 3”), with the possibility of further improvements. Prognosis By considering the improvements in the patient’s neurological state and the course of recovery of his functioning state since the injury, and taking into account existing evidence about the relationship between the AIS score and walking recovery,20 the prognosis was favorable. The patient’s mobility and ability to walk were expected to im1046

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prove. The identified environmental and personal factors would contribute to the patient’s improvements in functioning. However, a complete neurological and functional recovery by the end of the actual inpatient rehabilitation program seemed to be unlikely because of the extent of spinal cord damage and the remaining length of only 8 weeks of the program.

Number 7

Plan of Care Goals were established in terms of the components of the ICF in collaboration with the rehabilitation team and the patient and determined by considering the prognosis (expected neurological improvements and facilitating environmental and personal factors). The patient indicated that his goal was to reintegrate into the community and live independently. The patient’s long-term goal (LTG), which was expected to be achieved at the end of the rehabilitaJuly 2010

Application of the ICF in Multidisciplinary Patient Management tion program, was the resumption of leisure activities (eg, running, riding a bicycle) and to be able to swim and drive his car. Two short-term goals (STGs) were defined. The first shortterm goal (STG1) was to improve locomotion, specifically to be able to walk safely with forearm crutches inside buildings. The second shortterm goal (STG2) was to improve his ability with carrying, handling, and moving objects, specifically to be able to perform independently all hand-related tasks. These goals were entered into the ICF Categorical Profile. Based on the goal setting, intervention targets were selected from the list of ICF categories that were included in the ICF Categorical Profile. To become an intervention target, an ICF category has to have an impact on a goal, has to be modifiable, and has to be relevant for the actual situation. With respect to STG1 (locomotion), the selected intervention targets included the patient’s reduced muscle power, his involuntary movement functions, and his impairments in muscle tone functions, gait patterns, and coordination of voluntary movements. The impaired respiration, exercise tolerance, and muscle endurance functions also were identified as factors that contributed to the patient’s limited locomotion. Activities such as changing and assuming specific body positions, walking long distances or in different environments, driving, and engaging in sports activities also were selected as intervention targets. Furthermore, the optimization of environmental factor “assistive devices” (eg, forearm crutches, wheelchair) should contribute to facilitate locomotion. The intervention targets related to STG2 (carrying, handling, and moving objects) are shown in the ICF Categorical Profile (Fig. 2). Notably, there were a number of intervention targets that overlapped with STG1. July 2010

For each of the STGs and intervention targets, a goal value (again, using the ICF qualifier) that was realistic to be achieved in 8 weeks was defined by the rehabilitation team. The time frame for the achievement of the STGs was according to the patient’s planned discharge, when the further steps of his rehabilitation should be decided.

Intervention Interventions provided by the physical therapist are presented in the documentation template under the column “Intervention ⫹ Frequency” (Tab. 1). The ICF Intervention Table12 with selected codes as examples is shown in Table 2. To illustrate the complete intervention plan, the ICF Intervention Table12 (see eTab. 2, available at ptjournal. apta.org) contains a comprehensive overview of all interventions and the corresponding health care professionals who would address an intervention target. Given the 2 STGs, the majority of the interventions were assigned to the physical therapist, occupational therapist, and sports therapist, who may have overlapping interventions to a certain extent. A social worker and a certified driving instructor also were part of the team. Nursing assistance was not necessary anymore, except for administering medications. The physical therapist implemented a variety of specific techniques to improve the patient’s movementrelated functions. To reduce pain and to increase mobility in the patient’s right shoulder, manual therapeutic techniques, including active and passive movement techniques, were applied. To improve the patient’s respiratory functions, reflex locomotion (Vojta therapy)21 was performed. Because general exercise activity is essential in people with SCI,22 various aspects of general exercise activity were addressed. To increase exercise tolerance, the pa-

tient was instructed to perform arm ergometer training.23 To stimulate and improve muscle power functions, the physical therapist again used reflex locomotion, and the sport therapist instructed and supervised strengthening exercises with equipment.24 To activate the patient’s impaired involuntary movement reaction functions, which increased his risk for falls,25,26 balance exercises comprising the shifting of the center of gravity were administered by the physical therapist and completed within table tennis training supervised by the sport therapist. Regarding problems with gait, the physical therapist addressed gait patterns and walking within specific exercises inside and outside of the parallel bars,27 and later on different terrains and around obstacles. In the later phase, sport activities also were incorporated to test the patient for skills that are required in different types of recreational activities that would be essential to contribute to the patient’s quality of life.28 To address the impact of a community environment on gait performances,29 the patient was assigned to a specific “city training” performed by the occupational therapist. The assignment of interventions and health care professionals for the STG of handling objects also is shown in the ICF Intervention Table (Tab. 2 and eTab. 2). The main responsibility to perform these interventions was assigned to the occupational therapist. Other interventions included in the plan of care were safety driving by a certified instructor and the job arrangement with his former employer with the aid of a vocational counselor.

Outcome Over the next weeks of rehabilitation, the patient’s functioning continued to improve. Seven months postinjury and shortly before his planned discharge, a re-examination

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Gait pattern functions

b770

Dressing

Remunerative employment

Recreation and leisure

d540

d850

d920

Assistive products and technology for personal indoor and outdoor mobility and transportation

Moving around in different locations

Walking long distances

d460

d4501

Therapeutic games

Once, 5 h

4⫻/sport program (30 min) 3⫻/OT program, adaptation and counseling

Swim training Optimization of wheelchair

4⫻/wk, 30 min

Once, 3 h

Participation in various sport activities

Counseling and clarification with former employer

Daily

Outdoor training (city training) Assistance and instruction

PT program: 7ⴛ/wk, 30 min

4⫻/wk, 30 min

PT program: 7ⴛ/wk, 30 min

OT program: 7⫻/wk, 30 min

Outdoor training (area around center)

Walking endurance training

Gait training/outdoor training

Hand and arm use

3⫻/wk, 30 min

Table tennis OT program: 7⫻/wk, 30 min

PT program: 7ⴛ/wk, 30 min

PT program: 7ⴛ/wk, 30 min

Body balance training on unstable surface

Repetitive training of transfers

Therapeutic games

Walking short distances

e120

3⫻/wk, 30 min PT program: 7ⴛ/wk, 30 min

Table tennis Gait training in parallel bars

PT program: 7ⴛ/wk, 30 min

Daily drug intake

3⫻/wk, 30 min

4⫻/wk, 30 min

PT program: 7ⴛ/wk, 30 min

4⫻/wk, 30 min

PT program: 7ⴛ/wk, 30 min

Intensity

Body balance training on instable surface

Medical treatment

Reflex locomotion (Vojta therapy)

Strength training with equipment

Fine hand function

d4500

d445

d440

Maintaining a standing position

Involuntary movement reaction functions

b755

d4154

Tone of muscles of lower half of the body

b7353

Standing

Power of muscles of the trunk

b7305

d4104

Power of muscles of all limbs

b7304

Ergometer training

Exercise tolerance functions

Mobility of joint functions

b455

b710

Passive and active movement of joints

Manual therapy

Sensation of pain

b280

Type

X

MD

X

X

Nurse

X

X

X

X

X

X

X

X

X

X

PT

X

X

X

X

X

X

X

X

X

SPO

X

X

X

X

X

X

OT

X

SW

X

Others

⫹3

3

2

1

3

3

3

2

3

2

2

3

2

1

2

2

2

1

2

Evaluation Valueb

⫹4

1

1

0

1

1

0

1

1

0

1

1

1

0

1

1

1

0

0

Goal Valueb

a Intervention targets that were assigned to the physical therapist are marked in bold letters. MD⫽medical doctor, PT⫽physical therapist/physical therapy, SPO⫽sport therapist, OT⫽occupational therapist/ occupational therapy, SW⫽social worker. b ICF qualifiers describe the value of the evaluation based on examination and re-examination and for the goal and range from 0 (no problem) to 4 (complete problem) in the components of body functions (b), body structures (s), and activity and participation (d) and from 4 (complete barrier) to ⫹4 (complete facilitator) in the environmental factors.

Environmental factors

Activity and Participation

Body Functions

Intervention Targets–ICF Categories

Intervention

International Classification of Functioning, Disability and Health (ICF) Intervention Table12: Selected Codes as Examples

Table 2.

Application of the ICF in Multidisciplinary Patient Management

July 2010

Application of the ICF in Multidisciplinary Patient Management

Figure 4. International Classification of Functioning, Disability and Health (ICF) Evaluation Display.12 The list includes all ICF categories that were identified as intervention targets. †ICF qualifiers ranged from 0 (no problem) to 4 (complete problem) in the components of body functions (b), body structures (s), and activity and participation (d) and from 4 (complete barrier) to ⫹4 (complete facilitator) in the environmental factors.

of his level of functioning in all intervention targets was performed. The results of the physical therapist’s reexamination were entered in the documentation template in the column “Re-examination” (Tab. 1). The changes in the patient’s level of functioning were evident. The AIS score improved to AIS grade D (“motor function is preserved below the neurological level, with at least half of the key muscles graded at 3 or better”) and the Spinal Cord Independence Measure score achieved a total of 93 out of 100. With respect to locomotion (STG1), muscle power functions increased partially from grade 3/5 and grade 4/5 to grade 5/5 for many muscles, howJuly 2010

ever, both lower limbs still showed reduced muscle power. The exercise tolerance functions also remained slightly impaired. The patient rated his exercise tolerance on the Borg Rating Scale as 10 out of 100. During the re-examination, the patient’s muscle tone function was found to be normal. These improvements appeared to contribute to improved gait pattern and increased control of voluntary movements. The patient was now able to walk independently for up to 15 minutes without assistive devices. However, when he walked outdoors, the use of forearm crutches or a wheelchair was still required to avoid limping caused by muscular exhaustion. Accordingly,

he was able to climb only 3 flights of stairs and was unable to run. The interventions that aimed to achieve STG2 (carrying, handling, and moving objects) also appeared to have contributed to his overall functional improvements. The assessment of the range of motion of the patient’s right shoulder resulted in an increase in flexion from 110 – 0 –20 to 160 – 0 –20 degrees. Based on a dynamometer analysis, the patient demonstrated an increase in muscle power functions in both hands of up to 50%. Although this finding may have represented a significant gain, for comparison, it still was less than half of the hand force produced by matched men without

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Application of the ICF in Multidisciplinary Patient Management SCI.30 The reduced muscle power and persistent absence of sensation appeared to contribute to difficulty in carrying out some daily tasks such as typing, changing a printer cartridge, or carrying heavy jars. Nevertheless, he reported confidence in many other daily tasks such as holding a cup to drink and preparing simple meals. The re-examination of the patient’s LTG (recreation and leisure) resulted in some modest gains. Regarding sport activities, he was now able to ride a bicycle with a small frame on flat areas with no traffic. As stated previously, the results again were rated with the ICF qualifiers to define the final value and entered into the ICF Evaluation Display12 (Fig. 4) to provide comprehensive information to the team.

Discussion Conceptual frameworks help to guide communication and patient care.7 As described by Rauch et al12 and by Escorpizo et al13 (see companion perspective article in this issue), ICF-based documentation tools for multidisciplinary use and specific physical therapist’s documentation templates delineating relevant patient- and clinician-derived information have been developed to facilitate the translation of the ICF into patient-oriented and comprehensive management. This case report of a person with traumatic incomplete SCI showed how these ICF tools could be integrated into a systematic approach to patient management, which starts from a comprehensive description of impairments, limitations, and restrictions and progresses to providing the necessary intervention and discharge planning. Furthermore, this case report illustrates the benefit and the challenges of blending of the ICF in the form of ICF Core Sets and the ICF qualifiers and the processes of daily physical therapist practice as contained in the Guide. 1050

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In the perspective article by Escorpizo et al13 in this issue, it is suggested that the ICF be integrated with the Guide by using ICF Core Sets to develop a documentation template. This template was meant to facilitate efficiency in clinical documentation by physical therapists while encouraging the application of the ICF. The use of the proposed template will allow physical therapists an ICF-based documentation of their specific patient management. This case report illustrates how the documentation template for physical therapists comprises all relevant information for the physical therapist’s patient management by structuring the encounter between the physical therapist and the patient, resulting in the documentation of standard measures by way of the ICF categories within the processes as prescribed in the Guide. This approach aids in the clinical decision-making process and at the same time helps in the identification of appropriate strategies toward positive treatment outcomes. This case report has further illustrated how this template and previously developed ICF-based documentation tools for multidisciplinary care complement one another and thus enhance multidisciplinary patient management.12 The use of the ICF Core Sets for SCI in the postacute context provided guidance in the examination performed by the whole team. The use of ICF Core Sets can help clinicians in identifying aspects of functioning that need to be assessed in their patients. Furthermore, the use of ICF Core Sets can pave the way for how to standardize documentation and subsequently provide a way for creating meaningful group-level data. As a result of using the ICF Core Set in combination with the rating of the extent of a problem in ICF categories with the ICF qualifiers, a comprehensive profile of the patient’s function-

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ing state can be created and provided within the ICF Categorical Profile to all team members. Furthermore, the ICF Categorical Profile clearly illustrates the shared goals and facilitates the determination of intervention targets which are related to the goals. Consideration of patients’ perspectives of their life situation has always been a cornerstone of patient management. Patient-identified problems are important to develop a hypothesis that later could guide intervention.31 The ICF Assessment Sheet includes the patient perspective and thereby adds rich information to the ICF categories about the patient’s own experience. Furthermore, it supports the diagnostic process by facilitating the identification of hypothesized relationships between problems and their causes, which is an important step in the clinical reasoning process. Both the documentation template and the ICF Intervention Table support the generation of the patient’s plan of care. By clearly outlining the intervention targets, they facilitate the assignment of necessary interventions and responsible professionals. Because the ICF Intervention Table is comprehensive, the roles of the physical therapists and other team members are made clear, which is essential to enhance professional working relationships.32 In consequence, the ICF Intervention Table may help to avoid overlap or redundancy among team members, given a multidisciplinary health care setting. The ICF Evaluation Display illustrates the results and evaluation of the reexamination, which can provide a snapshot of a change in the patient’s comprehensive functioning state and thereby contribute to further treatment planning. Beside the benefits, there are challenges that can be July 2010

Application of the ICF in Multidisciplinary Patient Management foreseen with the use of the ICF and the ICF-based documentation tools. The ICF qualifiers have been used as an aggregate rating scale to rate the extent of a problem in ICF categories based on information gathered within the examination and patient interview. The use of the ICF qualifiers provides generally understandable information; however, it was shown that the interrater reliability is only moderate and requires future operationalization of the ICF categories.33,34 The development of manuals might contribute to the collection of more reliable information.11,35 The operationalization of ICF categories by integrating instruments into psychometrically sound ICF category interval scales36,37 or the construction of new ICF-based clinical measures38 also could increase reliability in ICF-based descriptions of patients’ functioning states in the future. The administration burden (ie, feasibility) is another matter for consideration. The development of electronically documentation systems may support the practicability and thereby the acceptance of the use by health care professionals in daily routine. Future research is needed to examine and perhaps re-examine the approach illustrated in this case report on how to best implement the ICF among physical therapy and other rehabilitation therapy clinicians. Invited Commentary and Author Response follow on page 1064. All authors provided concept/idea/project design. Ms Rauch, Dr Escorpizo, Dr Riddle, and Dr Cieza provided writing. Ms Rauch provided data collection and analysis. Ms Rauch and Dr Cieza provided project management. Dr Escorpizo, Dr Riddle, Dr EriksHoogland, and Dr Cieza provided consultation (including review of manuscript before submission). The authors thank Franziska Egli and the rehabilitation team of Swiss Paraplegic Center for their invaluable support to this project.

July 2010

This article was received October 6, 2009, and was accepted April 12, 2010. DOI: 10.2522/ptj.20090327

References 1 Stucki G, Cieza A, Melvin J. The International Classification of Functioning, Disability and Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy. J Rehabil Med. 2007; 39:279 –285. 2 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746. 3 Biering-Sorensen F, Scheuringer M, Baumberger M, et al. Developing core sets for persons with spinal cord injuries based on the International Classification of Functioning, Disability and Health as a way to specify functioning. Spinal Cord. 2006;44: 541–546. 4 Kirshblum SC, Priebe MM, Ho CH, et al. Spinal cord injury medicine, 3: rehabilitation phase after acute spinal cord injury. Arch Phys Med Rehabil. 2007;88:S62–S70. 5 Cieza A, Stucki G. Understanding functioning, disability, and health in rheumatoid arthritis: the basis for rehabilitation care. Curr Opin Rheumatol. 2005;17:183–189. 6 International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organization; 2001. 7 Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734. 8 World Confederation for Physical Therapy. 15th WCPT General Meeting; June 7–12, 2003; Barcelona, Spain. 9 Cieza A, Ewert T, Ustun TB, et al. Development of ICF Core Sets for patients with chronic conditions. J Rehabil Med. July 2004(44 suppl):9 –11. 10 Grill E, Ewert T, Chatterji S, et al. ICF Core Sets development for the acute hospital and early post-acute rehabilitation facilities. Disabil Rehabil. 2005;27:361–366. 11 Stucki G, Kostanjsek N, Ustun B, Cieza A. ICF-based classification and measurement of functioning. Eur J Phys Rehabil Med. 2008;44:315–328. 12 Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008; 44:329 –342. 13 Escorpizo R, Stucki G, Cieza A, et al. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1053–1063. 14 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9 –746, rev 2003. 15 Standard neurological classification of spinal cord injury; 2006. Available at: http:// www.asia-spinalinjury.org/publications/ 2006_Classif_worksheet.pdf. Accessed February 19, 2009.

16 Kirchberger I, Cieza A, Biering-Sørensen F, et al. ICF Core Sets for individuals with spinal cord injury in the early post-acute context. Spinal Cord. September 29, 2009 [Epub ahead of print]. 17 van Drongelen S, de Groot S, Veeger HE, et al. Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury. Spinal Cord. 2006;44: 152–159. 18 Eriks-Hoogland IE, de Groot S, Post MW, van der Woude LH. Passive shoulder range of motion impairment in spinal cord injury during and one year after rehabilitation. J Rehabil Med. 2009;41:438 – 444. 19 Barbeau H, Ladouceur M, Norman KE, et al. Walking after spinal cord injury: evaluation, treatment, and functional recovery. Arch Phys Med Rehabil. 1999;80: 225–235. 20 Kay ED, Deutsch A, Wuermser LA. Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury. Arch Phys Med Rehabil. 2007;88: 745–750. 21 Vojta V. The basic elements of treatment according to Vojta. In: Scrutton D, ed. Management of the Motor Disorders of Children With Cerebral Palsy. Philadelphia, PA: Spastics International Medical Publications; 1984:75– 84. 22 Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Med. 2004;34:727–751. 23 Raymond J, Davis GM, Climstein M, Sutton JR. Cardiorespiratory responses to arm cranking and electrical stimulation leg cycling in people with paraplegia. Med Sci Sports Exerc. 1999;31:822– 828. 24 Jacobs PL, Nash MS, Rusinowski JW. Circuit training provides cardiorespiratory and strength benefits in persons with paraplegia. Med Sci Sports Exerc. 2001;33: 711–717. 25 Leroux A, Fung J, Barbeau H. Postural adaptation to walking on inclined surfaces, II: strategies following spinal cord injury. Clin Neurophysiol. 2006;117:1273–1282. 26 Brotherton SS, Krause JS, Nietert PJ. Falls in individuals with incomplete spinal cord injury. Spinal Cord. 2007;45:37– 40. 27 Amatachaya S, Keawsutthi M, Amatachaya P, Manimmanakorn N. Effects of external cues on gait performance in independent ambulatory incomplete spinal cord injury patients. Spinal Cord. 2009;47:668 – 673. 28 Beringer A. Spinal cord injury and outdoor experiences. Int J Rehabil Res. 2004;27: 7–15. 29 Olmos LE, Freixes O, Gatti MA, et al. Comparison of gait performance on different environmental settings for patients with chronic spinal cord injury. Spinal Cord. 2008;46:331–334. 30 Mathiowetz V, Kashman N, Volland G, et al. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil. 1985;66:69 –74.

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Application of the ICF in Multidisciplinary Patient Management 31 Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83: 455– 470. 32 Tempest S, McIntyre A. Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation. Disabil Rehabil. 2006;28:663– 667. 33 Grill E, Mansmann U, Cieza A, Stucki G. Assessing observer agreement when describing and classifying functioning with the International Classification of Functioning, Disability and Health. J Rehabil Med. 2007;39:71–76.

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34 Starrost K, Geyh S, Trautwein A, et al. Interrater reliability of the extended ICF core set for stroke applied by physical therapists. Phys Ther. 2008;88:841– 851. 35 Reed G, Lux J, Bufka L, et al. Operationalizing the International Classification of Functioning, Disability and Health in clinical settings. Rehabil Psychol. 2005; 50:22–31. 36 Grill E, Stucki G. Scales could be developed based on simple clinical ratings of International Classification of Functioning, Disability and Health Core Set categories. J Clin Epidemiol. 2009;62: 891– 898.

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37 Cieza A, Hilfiker R, Boonen A, et al. Items from patient-oriented instruments can be integrated into interval scales to operationalize categories of the International Classification of Functioning, Disability and Health. J Clin Epidemiol. 2009;62:912– 921, 921 .e1–3. 38 Cieza A, Hilfiker R, Chatterji S, et al. The International Classification of Functioning, Disability and Health could be used to measure functioning. J Clin Epidemiol. 2009;62:899 –911.

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Focus on the ICF R. Escorpizo, PT, DPT, MSc, is Research Scientist, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany.

Creating an Interface Between the International Classification of Functioning, Disability and Health and Physical Therapist Practice Reuben Escorpizo, Gerold Stucki, Alarcos Cieza, Kandace Davis, Teri Stumbo, Daniel L. Riddle The American Physical Therapy Association (APTA) has endorsed the International Classification of Functioning, Disability and Health (ICF) as a framework to be integrated into physical therapist practice. The ICF is a universal and inclusive platform for the understanding of health and disability and a comprehensive classification system for describing functioning. The APTA’s Guide to Physical Therapist Practice was designed to guide patient management, given the different settings and health conditions that physical therapists encounter in their daily clinical practice. However, physical therapists may be unclear as to how to concretely apply the ICF in their clinical practice and to translate the application in a way that is meaningful to them and to their patients. This perspective article proposes ways to integrate the ICF and the Guide to Physical Therapist Practice to facilitate clinical documentation by physical therapists.

G. Stucki, MD, MS, is Professor and Chair, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; Director, Swiss Paraplegic Research, Guido A. Za¨ch Strasse 4, CH-6207 Nottwil, Switzerland; and Director, ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. Address all correspondence to Dr Stucki at: gerold. [email protected]. A. Cieza, PhD, MPH, is Senior Scientist, Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany; Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. K. Davis, PT, DPT, is Faculty Member, College of Health Sciences and Post-Professional Doctor of Physical Therapy Program, Des Moines University, Des Moines, Iowa, and Physical Therapist, Sandhills Physical Therapy & Sports Rehab, North Platte, Nebraska. Author information continues on next page.

Post a Rapid Response to this article at: ptjournal.apta.org July 2010

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Creating an Interface Between the ICF and Physical Therapist Practice T. Stumbo, PT, MS, is Associate Professor and Associate Dean, College of Health Sciences, Des Moines University, and Director, Post-Professional Doctor of Physical Therapy Program, Des Moines University. D.L. Riddle, PT, PhD, FAPTA, is Otto D. Payton Professor, Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia. [Escorpizo R, Stucki G, Cieza A, et al. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1053–1063.] © 2010 American Physical Therapy Association

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he World Confederation for Physical Therapy during its 15th General Meeting in June 2003 adopted a motion1 supporting the implementation of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization.2 Five years later, the American Physical Therapy Association (APTA) officially endorsed the ICF.3 However, we found scarce evidence to indicate that the ICF has been integrated into physical therapist practice documentation. There have been 2 case reports illustrating the application of the ICF in physical therapist practice.4,5 The ICF as a practice framework in physical therapy also has been discussed in various settings, such as in cancer rehabilitation,6 pediatric rehabilitation,7 and management of neck pain8 and as a model for identifying intervention strategies in multi-setting and multi-health conditions where physical therapy is one of the health services provided.9 –11 Rauch et al12 demonstrated the use of the ICF as a basis for developing tools for clinicians. Clinical guidelines in physical therapist practice have been linked to the ICF as a reference to navigate through the process of patient management—from examination to intervention.8,13,14

Available With This Article at ptjournal.apta.org • eAppendix: International Classification of Functioning, Disability and Health (ICF) of the World Health Organization • Discussion Podcast: See the PTJ Web site for participants. • Audio Abstracts Podcast

All of these reports have contributed to the effort to implement the ICF in physical therapist practice. Although the support for the conceptual application of the ICF to clinical practice is evident from these reports, a welldefined documentation approach in physical therapist practice remains a challenge. Integrating the ICF into clinical documentation during clinical encounters needs to be explored. Specifically, there is a need to identify ways by which the ICF can be integrated into current forms of documentation in clinical practice. If ICF-based documentation approaches could be developed, clinical care would potentially benefit from the use of standardized documentation using an internationally agreed-upon standard. Therapists would better communicate with each other by avoiding the use of confusing or vague terms in documentation. One purpose of this perspective article is to present arguments in favor of the systematic and well-defined utilization of the ICF in physical therapy practice documentation. A second purpose is to propose the use of a clinical evaluation template that integrates APTA’s Guide to Physical Therapist Practice15 (herein referred to as the “Guide”) and the ICF. To accomplish these purposes, this article is structured in the following way. First, we discuss the Guide and its relation to the ICF. Second, we propose and discuss 2 ways of integrating the ICF with the templates described in the Guide. We discuss the added value of the ICF and ICF Core Sets to clinical practice. Because we do not discuss the ICF in great detail in this article, we direct readers to the accompanying background paper on the ICF (see eAppendix, available at ptjournal.apta.org) if more information is needed.

This article was published ahead of print on May 6, 2010, at ptjournal.apta.org.

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Creating an Interface Between the ICF and Physical Therapist Practice

The Guide to Physical Therapist Practice Purposes of the Guide The Guide is a resource for students, individuals who are engaged in the clinical practice of physical therapy, and those teaching and conducting research in physical therapy. The Guide addresses issues that affect and contribute to physical therapy as an independent health care profession. The Guide was designed to serve several purposes—namely to recognize the various settings in which physical therapists practice, to provide descriptions of physical therapy as a practice, to define standard terminology and provide a frame of reference, to enumerate assessment tools and tests and interventions that can be utilized during patient encounters, and to emphasize the principles of outcome measurement to gauge the effect and quality of care provided by physical therapists. These purposes hold relevance not only to physical therapists and their patients but also to others who influence health care such as policy makers, care managers, and service reimbursers.15 The Guide also may be used by the physical therapy scientific community to study diagnostic tests16,17 and to explore clinical decision making, reasoning, and treatment.18,19 In summary, the Guide lists a set of tools and resources to assist clinicians and researchers in finding ways to optimize patient management. Contents and Processes of the Guide Relevant outcome measures, a guide to intervention planning, and key processes in patient management are presented in the Guide. Processes that embody patient management are divided into 5 major elements: (1) examination, (2) evaluation, (3) diagnosis, (4) prognosis, and (5) intervention.15 Reference will be made

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throughout this perspective article to these terms as they are used in the current edition of the Guide.15 The Guide advises physical therapists on what to evaluate and provides resources (eg, questionnaires or scales, procedures, list of outcomes) on how to conduct the evaluation. Readers are referred to the Guide for the full contents and description of patient management.

The ICF The ICF2 was endorsed by the World Health Assembly in May 2001 to create a common language of the full spectrum of human functioning and disability. The ICF presents a system of classifications of the domains and categories of human functioning that can be used to describe the experience of health and disability and that provides a common language to communicate multiple aspects of patient care. The ICF conceptual framework of functioning and disability is based on the biopsychosocial model, in which functioning and disability are the outcomes of complex interactions among intrinsic features of the person and contextual factors, both environmental and personal. See the eAppendix for more information about the ICF.

Common Conceptual Perspectives of the Guide and the ICF Use of Nagi’s model20 along with emphasis on the continuum of care, in our opinion, align the Guide and the ICF at the conceptual level. The ICF as a well-defined conceptual framework and the Guide as a defining document of physical therapist practice share a common understanding of functioning and disability; thus, the ICF and the Guide complement each other. We believe that there are several reasons why the conceptual similarity between the 2 documents can provide a path toward integrat-

ing the ICF into physical therapist practice. Both the Guide and the ICF recognize the complex interaction between disability and functioning. For example, when treating a patient, a physical therapist can use the Guide to look for function domains that need close attention. These same function domains are defined in the ICF and are listed in the form of chapters and categories concerning the individual’s body functions, body structures, individual activities, and participation in a societal context. Moreover, both also consider the whole array of personal factors and environmental factors that may affect or influence the severity of disability, coping with the disease, and level of functioning. As movement specialists, physical therapists can use the Guide and the ICF to address “dysfunction” or disability with prudent consideration, not only of the patient as an individual but also of that individual’s role in the larger context of the community and through the continuum of health care—ranging from the acute setting to long-term care—irrespective of the health conditions or associated health-related events. We believe that these features support the argument that the Guide and the ICF can be made usable and practical when interfaced together. Knowledge of the conceptual similarities of the Guide and the ICF would be helpful because it would allow users of the Guide to integrate the ICF into daily practice. In the process, clinicians benefit because an ICF-based patient evaluation goes beyond the “traditional” view of consequences of disease at the level of body functions and body structures. Use of an ICF-based patient evaluation may facilitate more attention being paid to activity and participation domains, as well as environmental and personal factors, although re-

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Creating an Interface Between the ICF and Physical Therapist Practice a 䡺 Difficulty with locomotion/movement: (1) 䡺 Bed mobility (2) 䡺 Transfers (such as moving from bed to chair, from bed to commode) (3) 䡺 Gait (walking) (a) 䡺 On level

(c) 䡺 On ramps

(b) 䡺 On stairs

(d) 䡺 On uneven terrain

b 䡺 Difficulty with self-care (such as bathing, dressing, eating, toileting) c 䡺 Difficulty with home management (such as household chores, shopping, driving/transportation, care of dependents) d 䡺 Difficulty with community and work activities/integration (1) 䡺 Work/school (2) 䡺 Recreation or play activity

Figure 1. “Functional Status/Activity Level” section of the documentation template from the Guide to Physical Therapist Practice. Reprinted from the Guide to Physical Therapist Practice, 2003, rev 2nd ed, 2003, pages 702 and 704, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution requires written permission from APTA.

search is needed to test this hypothesis. Researchers also could develop an agenda that would foster the use and translation of ICF into practice, such as in point-of-care evaluation in the clinic.8,13,14 The ICF would provide a language and set of terms that will be common to the understanding of physical therapists regardless of their country of education and the region, culture, and traditional beliefs of the clinical setting in which they practice. In future revisions, the Guide could explore possibilities of how ICF categories could be made operational, practical, and feasible in a systematic manner using principles that are already fundamental to the Guide. Although the ICF provides us with “what” to measure, the Guide and future research efforts can aim to standardize ways of “how” to measure the “what.”

Foundation for Clinical Application: The ICF Core Sets For the ICF to be usable in a practical way, intermediate tools based on it are necessary. It is for this reason that the ICF Core Sets have been developed. A Core Set is a short and 1056

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manageable list of categories applicable to a health condition or healthrelated event that conveniently describe the most salient aspects of the disability experience related to that health condition or health event. Balancing the need for a workable instrument, in which only a small fraction of the ICF categories are used, and sufficient descriptive power to adequately describe the patient’s circumstance, each ICF Core Set is the product of extensive input from experts, patients, evidence in the literature, and empirical studies.21,22 A Core Set can be comprehensive or brief. A comprehensive Core Set usually is used in multidisciplinary assessment and has as few categories as possible to be practical but as many as necessary to capture the full spectrum of variables specific to a health condition or health-related event. A brief Core Set contains the minimum number of measures or categories to be included in studies on a health condition and is designed for use by a single discipline focused on a specific subset of problems, such as physical therapy.21 A Core Set also can be generic or condition-

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specific, depending on the type of health care setting where it is being used. ICF Core Sets for specific health conditions have been published. They are available for chronic conditions21 (eg, low back pain,23 stroke24) and for acute and postacute settings25 (neurological, musculoskeletal, and general medical conditions such as cancer). There are more upcoming Core Sets in the areas of vocational rehabilitation, hand conditions, traumatic brain injury, sleep, cerebral palsy, dementia, and Parkinson disease that are either in the development stage or nearing completion.26 Although an ICF Core Set is not available for all health conditions, there are many Core Sets that physical therapists can now integrate into their daily clinical practice. For conditions that do not yet have Core Sets or patients who have multiple conditions, an ICF generic Core Set has been proposed. The ICF generic Core Set consists of 28 categories from the different ICF components (body functions⫽10, activities and participation⫽17, environmental factors⫽1).27

Application of the ICF in Physical Therapist Practice This section of the article proposes 2 concrete ways in which the ICF could be integrated into patient management in physical therapist practice, specifically with consideration given to the documentation templates from the Guide.15(ppS699 –S711) First, we propose the use of the ICF generic Core Set in the subsection “Functional Status/Activity Level” of the history form in the documentation template. The second proposal is to recommend the use of condition-specific ICF Core Sets while using the elements of patient management of the Guide.

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Creating an Interface Between the ICF and Physical Therapist Practice Table. Suggested “Functional Status/Activity Level” Categories of Measures Based on the Generic Core Set of the International Classification of Functioning, Disability and Health (ICF) Body Functions (b) b130 Energy and drive functions

Activities and Participation (d)

Environmental Factors (e)

d1 Learning and applying knowledge

b134 Sleep functions

d230 Carrying out daily routine

b140 Attention functions

d3 Communication

b144 Memory functions

d410 Changing basic body position

b152 Emotional functions

d415 Maintaining basic body position

b210 Seeing

d430 Lifting and carrying objects

b230 Hearing

d450 Walking

b280 Pain

d455 Moving around

b710 Mobility of joint functions

d510 Washing oneself

b730 Muscle power functions

d530 Toileting

e450 Individual attitudes of health professionals

d540 Dressing d640 Doing housework d750 Informal social relationships d760 Family relationships d770 Intimate relationships d850 Remunerative employment d920 Recreation and leisure Any other body functions that the clinician may want to document outside of the generic Core Set (eg, blood pressure, respiratory rate, skin integrity)

Proposal 1: ICF-based “Functional Status/Activity Level” The documentation template of the Guide, located in the history section, contains a subsection titled “Functional Status/Activity Level.” Figure 1 lists the contents of this subsection in its current form. We contend that the “Functional Status/Activity Level” subsection in its current form is not comprehensive enough for clinical application. The items will not be able to capture all of the information pertaining to activities and participation of an individual from a personal level to the societal level. We propose that this subsection could be replaced with the 28 categories from the ICF generic Core Set. The generic ICF Core Set was found to provide a comprehensive descripJuly 2010

Any other activities and participation that the clinician may want to document outside of the generic Core Set (eg, school)

tion of functioning for individuals, and there is evidence that it demonstrates satisfactory validity in a number of domains.27 The generic ICF Core Set is brief enough, in our opinion, to be practical and capable of being implemented in daily practice for use with patients with multiple conditions and those for whom a specific Core Set has not been developed. The Table contains the list of categories belonging to the ICF generic Core Set. Based on Figure 1, the patient’s functional status covers bed mobility, transfers, walking, self-care, home management, work, and community and work integration (including school and recreation). However, information may not be captured for a patient who has a complex problem involving one or more complaints

Any other environmental factors that the clinician may want to document outside of the generic Core Set (eg, assistive devices, home setting, work environment, health services)

such as fatigue; pain; sleep, memory, or sensory system disturbances or complaints about aspects of mobility such as changing and maintaining body position, all of which are included in the ICF generic Core Set (Table). The Table contains categories that cover comprehensive yet practical information needed in routine clinical practice. The ICF handbook is not explicit as to whether the ICF categories should be assessed by the patient, the clinician, or both. We propose that the ICF categories be patient reported (instead of clinician rated) and that the limitation or restriction in a particular category be “qualified” using the first qualifier as presented in the ICF handbook.2 The ICF qualifiers use a global rating of impairment, limitation, or restriction in the form of numerical values as the first qualifier

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Creating an Interface Between the ICF and Physical Therapist Practice (0⫽no problem, 1⫽mild problem, 2⫽moderate problem, 3⫽severe problem, 4⫽complete problem, 8⫽not specified, and 9⫽not applicable). The category “environmental factors” can be reported as being a barrier or a facilitator to functioning. Based on the ICF handbook, each numerical value has a corresponding percentage range (0%– 4%, 5%–24%, 25%– 49%, 50%–95%, and 96%–100%, respectively). Therefore, a percentage value may be used as an option in addition to the numerical value.2(p226) For example, if a patient reported 25% impairment in muscle power function, which is ICF category b730 (included in the generic ICF Core Set), this percentage can be coded and qualified as category b730.2, denoting that the impairment is moderate (ie, 25% impaired). In our view, the ICF qualifier is not a substitute for other measures such as validated self-report measures or performance-based measures of physical function but rather is intended to complement them, producing a common reference across clinical settings and professions. Further research investigating the assessment of the ICF categories and qualifiers and the methodological limitations associated with these assessments is needed.28,29 This article suggests which domains or constructs to document as the initial basis for concretizing the ICF application. The degree or level of impairment or restriction in each ICF category of domain may be qualified according to the numerical rating scale (as the first qualifier)2 and later may be assigned a percentage value. To capture other categories or measures that the clinician would like to document, a space is provided at the end of the Core Set for each component (ie, column). Only the “Functional Status/Activity Level” section relates directly to the ICF. The remainder of the templates would not require revision, in our opinion. 1058

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Proposal 2: Integration of Condition-Specific ICF Core Sets Purpose of the Proposed Template We created a proposed template (Appendix) using the processes from the Guide as a reference. Table 2 could be helpful in the documentation of patient encounters from the initial examination to planning the intervention. The same table also could be used during the reexamination period and may be used in a variety of clinical settings (acute care, subacute care, skilled nursing facility, home health care, or outpatient facility) and in different health conditions (acute or chronic, musculoskeletal, neurological, cardiopulmonary, or integumentary). The use of this proposed template could be extended to multidisciplinary assessments such as those in a hospital setting where a patient is being seen by at least 2 different health care professionals. We recommend the use of condition-specific ICF Core Sets, as shown in the Appendix. Sections and Contents An important addition of the proposed template is the inclusion of the condition-specific ICF Core Sets. The osteoarthritis Core Set30 is presented here as an example. Several condition-specific Core Sets are available.21,22,25,26,31–35 We believe that the use of condition-specific Core Sets can make the clinical encounter both thorough and efficient.36,37 When used in a clinical encounter, the suggested documentation template shown in the Appendix would be administered and used together with the history section from the Guide template, which contains items on sociodemographics and other patient-reported health information. Imaging and laboratory findings that may be essential to clinical decision making can be considered

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supplementary information and can be added to the documentation. Elements of patient management mentioned earlier— examination, evaluation, prognosis (including plan of care), and intervention—and reexamination would be used similarly to how they are used in the Guide to facilitate a structured process. Crucial to patient management is the development of goals that are functional, measurable, outcomes driven, and patient centered and have a given time frame.38,39 Patient-oriented short-term goals (STGs) and long-term goals (LTGs) are reported in the first row of the suggested documentation template. Short-term goals are those that could be achieved in a shorter span of time (eg, 2 weeks) compared with LTGs, which involve a longer time period (eg, 4 weeks). Short-term goals and LTGs, however, are essentially similar in that both embody what would be considered a “meaningful change” to the patient37 and are ideally within the context of activities and participation of the patient. A section also is provided to specify diagnosis using Preferred Physical Therapist Practice Patterns15 or the ICD-10 codes.40 As illustrated in the Appendix, the examination section consists of ICF categories from the Core Set. The therapist makes decisions about which categories require examination (eg, “Do we need to examine category b280: Sensation of pain”?) and which test or instrument to use to measure or evaluate that category (eg, a 100-mm visual analog scale). The test values or results (eg, visual analog scale score for pain of 70 mm) then are recorded. In addition, the form illustrated in the Appendix allows for documentation of the LTG or STG (ie, related to a specific goal). For example, category b280 is related to the STG of decreasing pain from 70 mm to 20 mm, which could be related to the LTG of being able to July 2010

Creating an Interface Between the ICF and Physical Therapist Practice walk without an assistive device. The Appendix also allows for documentation of the corresponding prognosis relevant to the category, the intervention needed (eg, joint protection technique and therapeutic exercise), and specification of the frequency (eg, 5 times per week) and duration (eg, 2 weeks) of treatment. A re-examination is performed at an appropriate time (which may vary from setting to setting or from one health condition to another) where retesting of a category is conducted (ie, retest value) and a determination of whether the previously set goal was achieved. Near the end of the list of ICF categories, the physical therapist is provided with additional space for other ICF categories or measures that need to be documented in addition to the condition-specific ICF Core Sets being used. If during and after the examination the clinician finds personal factors such as those relating to age, sex, education, coping, and acceptance of disease that are believed to be relevant to treatment but not necessarily part of the health condition,2 a space is provided for documentation and for indicating whether the personal factors have a positive or negative influence on the patient’s recovery and whether they are modifiable. A full definition of personal factors is provided in the ICF handbook.2 At the bottom of the proposed template, a section is provided for writing down the evaluation and overall prognosis of the patient, considering all the information that has been obtained. A discharge plan also is to be provided. Physical therapists may add additional notes that need to be documented. By using the proposed template, intervention targets are identified according to the categories from the condition-specific ICF Core Sets with which patients were found to have an impairment or restriction that July 2010

could be addressed by the physical therapist. Thus, the physical therapist may elect to intervene on those categories that are within the scope of physical therapist practice. If other categories are identified as problematic but do not fall under the scope of physical therapy, the physical therapist can refer the patient to appropriate professionals or services.

Discussion The Guide provides clinicians with the content and resources regarding professional issues, including treatment outcomes and tools and necessary skills, all of which are integral to competent physical therapist practice. The ICF as a conceptual framework and classification system has been in existence for about 8 years, since its approval by the World Health Assembly of the World Health Organization. However, in our opinion, a significant gap remains between the use of the ICF and documentation by clinicians despite APTA’s endorsement of the ICF. There is a lack of systematic and concrete application of the ICF in clinical settings. In our opinion, the Guide and the ICF are complementary and could play an important role in advancing physical therapist practice. The Guide can provide a clear application of theoretical knowledge and processes that define the scope of physical therapist practice, and the ICF can be utilized both as a conceptual model and comprehensive classification system of functioning. Combining the Guide and the ICF also would provide a common language to facilitate communication among and within health care professions. In this article, we attempted to illustrate that the ICF and physical therapist practice share common conceptual perspectives. Thus, we

proposed 2 ways to integrate and apply the ICF in physical therapist practice: (1) using the ICF generic Core Set to represent the “Functional Status/Activity Level” subsection found in the documentation template of the Guide and (2) using condition-specific ICF Core Sets along with the systematic process of patient management of the Guide. The first proposal seeks to integrate the ICF in physical therapy documentation in a concise manner using modified documentation templates in the Guide. The benefit of using the ICF Generic Core Set is that it can be used in health conditions where an ICF Core Set is not available. The first proposal provides a simple way of integrating the ICF into the template by substituting the current contents of the “Functional Status/ Activity Level” subsection of the template with the ICF generic Core Set. The generic Core Set, which was developed for a wide range of conditions and health care settings, is ideally suited for the clinical examination and evaluation of the patient’s level of functioning and disability. The generic Core Set is self-reported and, therefore, is based on the patient’s perspective and together with other clinician-derived information would be helpful in determining appropriate goals, prognosis, and the required intervention. One important caveat is that neither the ICF, as a classification, nor the ICF generic Core Set, as an extraction from it, should be considered a substitute for standard clinical outcome measures. Psychometric evidence (reliability and responsiveness to change) for ICF-derived measures is lacking. In our view, ICF qualifiers (ie, numerical values) in concert with other specific clinical outcome instruments, such as the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire,41 the Oswestry Disability Index,42 and the Health Assessment Questionnaire,43

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Creating an Interface Between the ICF and Physical Therapist Practice Ways to integrate the ICF in clinical documentation: 1. Use the ICF generic Core Set to reflect functional status and activity level.

vices,45 and a similar effort in the field of physical therapy also may be useful.

2. Use ICF condition-specific Core Sets. 3. Use the elements of patient management from the Guide to Physical Therapist Practice. Benefits: 1. Implementation of a conceptual framework by the World Health Organization. 2. Standardization of outcome measures and establishment of minimum data for each clinical encounter. 3. Flexibility afforded by using ICF condition-specific Core Sets. 4. Comparability of data across practice settings and countries for clinical and research purposes. Challenges: 1. Lack of consensus on the standard outcome measures to be used to operationalize each ICF category. 2. Administration burden to clinicians.

Figure 2. Summary of the International Classification of Functioning, Disability and Health (ICF) integration in physical therapist practice.

can be used to provide a comprehensive description of patients’ activity limitations and participation restrictions. The second proposal takes the integration of the ICF further by allowing for existing condition-specific ICF Core Sets to be used instead of the ICF generic Core Set. Using the condition-specific Core Set provides the physical therapist with greater specificity in documenting variables that hold practical relevance for the patient.

Challenges and Opportunities There are challenges to face regarding the full integration of ICF in the Guide, particularly regarding daily practice documentation. The ICF Core Sets (both generic and condition-specific) define only what to measure and not how to measure. Although the contents of the ICF categories demonstrate content validity, the reliability and responsiveness of these Core Sets have yet to be extensively tested. Defining how to measure each category in the ICF Core Sets is a future 1060

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research need in physical therapist practice. For example, the physical therapist might want to test the category d450 (Walking) in terms of distance walked or speed of walking. The selection of “standardized” tests to operationalize each category ideally would be based on existing evidence. As an example, Paul et al44 found that a back muscle endurance test is a good indicator of muscle function based on the brief version of the ICF Core Set for chronic LBP, and similar studies would be useful to this end. Further studies would need to be conducted to look at potential “standard” tests or procedures that could be used by clinicians. Some measures in the ICF generic Core Set, such as “learning and applying knowledge” and “communication,” may be too general, although the ICF does provide more precise categories and subcategories under each measure. Although the ICF categories can be specified further by the clinician based on the ICF handbook,2 this may introduce variability, making it difficult to compare patients. The American Psychological Association has pushed for efforts to standardize the operationalization of the ICF in providing ser-

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Another challenge is to ensure that clinicians fully understand and can apply the ICF. This challenge could be addressed by use of the ICF handbook2 or by consulting the ICF online browser (http://apps.who.int/classifi cations/icfbrowser). An e-learning tool (software) on the ICF developed by the World Health Organization was launched in 2008 and is currently being tested. The e-learning tool is expected to facilitate distance learning in a condensed and convenient way. As it has been a major issue often raised, the lack of classification of personal factors in the current version of the ICF poses some limitation because there is evidence to suggest that personal factors are an important consideration in patient care.46,47 To address this issue, space is provided in our proposed template to document personal factors of the patient that clinicians believe are relevant to successful treatment outcomes. As a matter of feasibility, the burden to the physical therapist may be a challenge. Implementing the ICF in clinical evaluation and documentation may mean more time spent on each encounter with a patient relative to what clinicians are accustomed. However, we believe that small increases in time spent on documentation will add value to the documentation, particularly when the patient is seen by different clinicians or when group data are examined. Keeping this burden of administration to a minimum is key to achieving clinical feasibility and wide acceptability by physical therapist clinicians. Figure 2 summarizes the recommendations of this article on how to implement the ICF in documentation in clinical practice and the limitations. It would be beneficial for physical therapy as a field to be aligned with July 2010

Creating an Interface Between the ICF and Physical Therapist Practice the ICF model of functioning and disability in order to link physical therapists’ understanding of patients and patient care with that of other health care providers in a consistent manner.48 The proposals that we have stated here are, in our opinion, straightforward ways of integrating the ICF into the existing documentation template (proposal 1) as provided in the Guide. We have presented and discussed the interface between the Guide and the ICF, which we believe will assist in advancing the scientific practice of physical therapy. Dr Escorpizo, Professor Stucki, Dr Cieza, and Dr Riddle provided concept/idea. All authors provided writing and reviewed the manuscript before submission. Professor Stucki, Dr Cieza, and Dr Riddle provided consultation. The authors thank the Case Study Group at the Swiss Paraplegic Research for sharing their perspectives on the manuscript. Special thanks to Professor Jerome Bickenbach and Alexandra Rauch for their comments on the manuscript prior to submission. This article was received October 6, 2009, and was accepted February 25, 2010. DOI: 10.2522/ptj.20090326

References 1 World Confederation for Physical Therapy (WCPT). 15th WCPT General Meeting; June 4, 2003; Barcelona, Spain. 2 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 3 American Physical Therapy Association. ICF International Classification of Functioning, Disability and Health resources. Available at: http://www.apta.org/AM/ Template.cfm?Section⫽Home&TEMPLATE ⫽/CM/ContentDisplay.cfm&CONTENTID ⫽51922. Accessed October 13, 2008. 4 Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s International Classification of Functioning, Disability and Health. Phys Ther. 2009;89: 82–90. 5 Helgeson K, Smith AR Jr. Process for applying the International Classification of Functioning, Disability and Health model to a patient with patellar dislocation. Phys Ther. 2008;88:956 –964.

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6 Gilchrist LS, Galantino ML, Wampler M, et al. A framework for assessment in oncology rehabilitation. Phys Ther. 2009;89: 286 –306. 7 Darrah J, Wiart L, Magill-Evans J. Do therapists’ goals and interventions for children with cerebral palsy reflect principles in contemporary literature? Pediatr Phys Ther. 2008;20:334 –339. 8 Childs JD, Cleland JA, Elliott JM, et al. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A34. 9 Finger ME, Cieza A, Stoll J, et al. Identification of intervention categories for physical therapy, based on the International Classification of Functioning, Disability and Health: a Delphi exercise. Phys Ther. 2006;86:1203–1220. 10 Allet L, Cieza A, Burge E, et al. Intervention categories for physiotherapists treating patients with musculoskeletal conditions on the basis of the International Classification of Functioning, Disability and Health. Int J Rehabil Res. 2007;30: 273–280. 11 Burge E, Cieza A, Allet L, et al. Intervention categories for physiotherapists treating patients with internal medicine conditions on the basis of the International Classification of Functioning, Disability and Health. Int J Rehabil Res. 2008;31: 43–50. 12 Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008; 44:329 –342. 13 Cibulka MT, White DM, Woehrle J, et al. Hip pain and mobility deficits-hip osteoarthritis: clinical practice guidelines linked to the International Classification of Function, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2009;39:A1–A25; erratum 2009;39:297. 14 McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guildelines linked to the International Classification of Function, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A18; erratum 2008;38:648. 15 Guide to Physical Therapist Practice. Revised 2nd ed. Alexandria, VA: American Physical Therapy Association; 2003. 16 Andrews AW, Folger SE, Norbet SE, Swift LC. Tests and measures used by specialist physical therapists when examining patients with stroke. J Neurol Phys Ther. 2008;32:122–128. 17 Jette DU, Halbert J, Iverson C, et al. Use of standardized outcome measures in physical therapist practice: perceptions and applications. Phys Ther. 2009;89:125–135.

18 Spoto MM, Collins J. Physiotherapy diagnosis in clinical practice: a survey of orthopaedic certified specialists in the USA. Physiother Res Int. 2008;13:31– 41. 19 Hendrick P, Bond C, Duncan E, Hale L. Clinical reasoning in musculoskeletal practice: students’ conceptualizations. Phys Ther. 2009;89:430 – 442. 20 Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965:100 –113. ¨ stu 21 Cieza A, Ewert T, U ¨ n B, et al. Development of ICF Core Sets for patients with chronic conditions. J Rehabil Med. 2004; (44 suppl):9 –11. 22 Kesselring J, Coenen M, Cieza A, et al. Developing the ICF Core Sets for multiple sclerosis to specify functioning. Mult Scler. 2008;14:252–254. 23 Cieza A, Stucki G, Weigl M, et al. ICF Core Sets for low back pain. J Rehabil Med. 2004;(44 suppl):69 –74. 24 Geyh S, Cieza A, Schouten J, et al. ICF Core Sets for stroke. J Rehabil Med. 2004: (44 suppl):135–141. 25 Grill E, Ewert T, Chatterji S, et al. ICF Core Sets development for the acute hospital and early post-acute rehabilitation facilities. Disabil Rehabil. 2005;27:361–366. 26 ICF Research Branch of the World Health Organization Collaborating Center of the Family of International Classifications. Institute for Health and Rehabilitation Sciences, Ludwig-Maximillian University. ICF Core Sets. Available at: http://www.icfresearch-branch.org / research / reaserchprojects.htm. Accessed August 11, 2009. 27 Cieza A, Geyh S, Chatterji S, et al. Identification of candidate categories of the International Classification of Functioning, Disability and Health (ICF) for a generic ICF core set based on regression modelling. BMC Med Res Methodol. 2006;6:36. 28 Jette AM, Norweg A, Haley SM. Achieving meaningful measurements of ICF concepts. Disabil Rehabil. 2008;30:963–969. 29 Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734. 30 Dreinho ¨ fer K, Stucki G, Ewert T, et al. ICF Core Sets for osteoarthritis. J Rehabil Med. 2004;(44 suppl):75– 80. 31 Pisoni C, Giardini A, Majani G, Maini M. International Classification of Functioning, Disability and Health (ICF) Core Sets for osteoarthritis: a useful tool in the follow-up of patients after joint arthroplasty. Eur J Phys Rehabil Med. 2008;44:377– 385. 32 Schwarzkopf SR, Ewert T, Dreinhofer KE, et al. Towards an ICF core set for chronic musculoskeletal conditions: commonalities across ICF Core Sets for osteoarthritis, rheumatoid arthritis, osteoporosis, low back pain and chronic widespread pain. Clin Rheumatol. 2008;27:1355–1361.

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Creating an Interface Between the ICF and Physical Therapist Practice 33 Biering-Sorensen F, Scheuringer M, Baumberger M, et al. Developing core sets for persons with spinal cord injuries based on the International Classification of Functioning, Disability and Health as a way to specify functioning. Spinal Cord. 2006;44: 541–546. 34 Scheuringer M, Stucki G, Huber EO, et al. ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities. Disabil Rehabil. 2005;27:405– 410. 35 Stoll T, Brach M, Huber EO, et al. ICF core set for patients with musculoskeletal conditions in the acute hospital. Disabil Rehabil. 2005;27:381–387. 36 Kirchberger I, Glaessel A, Stucki G, Cieza A. Validation of the comprehensive International Classification of Functioning, Disability and Health core set for rheumatoid arthritis: the perspective of physical therapists. Phys Ther. 2007;87: 368 –384. 37 Stamm TA, Cieza A, Coenen M, et al. Validating the International Classification of Functioning, Disability and Health comprehensive core set for rheumatoid arthritis from the patient perspective: a qualitative study. Arthritis Rheum. 2005;53:431– 439.

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38 Rothstein JM, Echternach JL, Riddle DL. The hypothesis-oriented algorithm for clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83: 455– 470. 39 Riddle DL, Rothstein JM, Echternach JL. Application of the HOAC II: an episode of care for a patient with low back pain. Phys Ther. 2003;83:471– 485. 40 World Health Organization. International Classification of Diseases (ICD-10). Available at: http://www.who.int/classifications/icd/en/. Accessed January 2009. 41 Ware JE,Jr, Sherbourne CD. The MOS 36item short-form health survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30:473– 483. 42 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25:2940 –2952. 43 Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980;23:137–145.

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44 Paul B, Leitner C, Vacariu G, et al. Lowback pain assessment based on the Brief ICF Core Sets: diagnostic relevance of motor performance and psychological tests. Am J Phys Med Rehabil. 2008;87: 452– 460. 45 Reed GM, Lux JB, Bufka LF, et al. Operationalizing the International Classification of Functioning, Disability and Health in clinical settings. Rehabil Psychol. 2005;50:122–131. 46 Whittemore R, Dixon J. Chronic illness: the process of integration. J Clin Nurs. 2008;17:177–187. 47 Wall CL, Ogloff JR, Morrissey SA. The psychology of injured workers: health and cost of vocational rehabilitation. J Occup Rehabil. 2006;16:513–528. 48 Jette AM. The changing language of disablement. Phys Ther. 2005;85:118 –119.

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Creating an Interface Between the ICF and Physical Therapist Practice Appendix. Suggested Documentation Template Using Condition-Specific International Classification of Functioning, Disability and Health (ICF) Core Sets: The Osteoarthritis Core Set, Brief Version, Is Provided As an Example Patient’s Goal: Long-term goal (LTG): 1, 2, 3 . . . Short-term goal (STG): 1, 2, 3 . . . Date

Diagnosis:

[MM-DD-YYYY]

[MM-DD-YYYY] Intervention ⴙ Frequency

Examination

ICF Categories-Intervention Targets (Sample: ICF Core Set for Osteoarthritisa)

Need to Examine? Yes/No

Test

Test Value

Related to STG/ LTG Number?

Reexamination

Retest Value

Prognosis

Goal Achieved? Yes/No

Body Functions b280 Sensation of pain b710 Mobility of joint functions b730 Muscle power functions Body Structures s730 Structure of upper extremity s750 Structure of lower extremity s770 Additional musculoskeletal structures related to movement Activities and Participation d445 Hand and arm use d450 Walking d540 Dressing Environmental Factors e115 Products and technology for personal use in daily living e150 Design, construction, and building products and technology of buildings for public use e310 Immediate family e580 Health services Other Categories: Personal Factors (Pf)

Influence Positive

Negative

Pf (eg, coping) Pf (eg, acceptance of disease) Evaluation and Overall Prognosis: Discharge Plan: Other Notes: a

Brief Core Set (n⫽13) for osteoarthritis.

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Commentary on the ICF and Physical Therapist Practice

Invited Commentary

Alan M. Jette

Escorpizo and colleagues1 present a thoughtful argument for the welldefined utilization of the International Classification of Functioning, Disability and Health (ICF)2 in physical therapist practice documentation. To accomplish this goal, they advocate for the systematic use of assessment tools based on the ICF, specifically, the ICF Core Sets.2,3 They propose that an ICF Core Set, a short and manageable list of categories applicable to a health condition or event, can be used in clinical practice to describe and monitor the most salient aspects of the disability experience related to a patient’s health condition or event. They advocate that each ICF Core Set, the product of a systematic development process that involved extensive input from experts, patients, and review of the literature, be used as the documentation template in physical therapy clinical encounters. In a companion article, Rauch et al4 illustrate how the ICF Core Sets might be used as a documentation template in a case report of a patient with spinal cord injury. I strongly endorse the use of the ICF framework as a common language to facilitate communication among and within health care professions.5,6 Furthermore, I applaud the authors’ stated goal that the physical therapy profession adopt systematic and concrete assessments based on the ICF framework for use in clinical encounters as a means of advancing physical therapist practice.7 The ICF classification of function and disability information, in principle, offers several attractive advantages.8 –11 The ICF framework establishes a common language for describing health-related states and provides a systematic classification scheme for health information systems. The

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comprehensiveness of ICF’s classification system could facilitate the widespread and systematic recording of functional status data in medical and rehabilitation patient records (at individual and institutional levels) and could influence universal design, public education, and legislation. Measures built from the ICF framework could permit comparison of health and healthrelated states across patients, studies, and countries, as well as across clinical services. Such measures could be used to compare the distribution and determinants of healthrelated states of different populations, predict health system usage and costs, and provide evidence for social policies and laws. However, I am skeptical as to whether the ICF Core Sets, given their current level of development, are worthy of being adopted as a comprehensive classification system of functioning and disability in physical therapist practice. I believe that without further research that clearly demonstrates the psychometric adequacy of the ICF Core Sets for such an application, it is premature to advocate that the ICF Core Sets be integrated into physical therapist practice documentation. My reasons for this skepticism are as follows. The ICF coding, which consists of a system for categorizing or classifying people’s health, functioning, and disability states, meets the basic definition of measurement: the assignment of symbols to objects, individuals, or events according to systematic rules. Measurements have 4 major purposes: categorization (or classification), discrimination between groups, prediction, and evaluating change.12 As measures, ICF Core Sets must meet basic psycho-

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metric standards, including reliability, validity, and responsiveness to clinically meaningful change. The ICF’s unit of classification is discrete categories within health and health-related states, defined as the situation of each person within an array of health and health-related domains. Using ICF coding, healthrelated states of an individual may be recorded by selecting the appropriate category code (a nominal measure) and then adding qualifiers (ordinal measures), which are numeric codes that specify the extent or the magnitude of the functioning or disability in that category. The qualifiers identify the presence and severity of a decrement in functioning for each ICF component (ie, body functions and structures, activities and participation, and environmental factors). Each ICF code denotes a component, domain, category, and at least one qualifier. The codes are alphanumeric, beginning with a letter and followed by up to 4 or 5 digits. Qualifiers are mostly coded as one or more numbers after a decimal point. For example, one could use the ICF coding approach to classify the walking ability of Mrs Jones, an 80-yearold woman with a hip fracture, as ICF code d450.32. This specific ICF code denotes that walking is in the activities and participation domain (alphabetical code d), the mobility domain (chapter 4), and the walking category (50) and that the patient has severe performance difficulty (3) and moderate difficulty with capacity (2). From a methodological perspective, the magnitude of measurement error inherent in using the ICF Core Sets is currently unknown. As the authors themselves conclude, “One important caveat is that neither the ICF, as

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Commentary on the ICF and Physical Therapist Practice a classification, nor the ICF generic Core Set, as an extraction from it, should be considered a substitute for standard clinical outcome measures. Psychometric evidence (reliability and responsiveness to change) for ICF-derived measures is lacking.”1 Is now the time to advocate using the ICF Core Sets as an evaluation and documentation system for use in physical therapist clinical practice? At the present stage of development, do we know the degree to which the ICF Core Set classifications are reliable when used by patients or by different therapists? Do we know the magnitude of measurement error when used over time to gauge a patient’s level of improvement? How is a clinician to evaluate changes in ICF codes such as those reported in Rauch and colleagues’ case report?4 Have the ICF Core Sets been subjected to thorough psychometric evaluation and testing in clinical applications such as those being advocated by the authors? The ICF single-item coding approach to categorization with qualifiers consists of nominal and ordinal level of measurement.13 I fear that singleitem measures such as these are fraught with considerable measurement error. For example, Okochi et al,14 in one of the few studies of test-retest reliability of the ICF Core Sets, found ICF qualifiers of body function and activities and participation items to have low test-retest re-

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liability within a 1-week interval with a sample of stable elderly individuals using long-term care services in Japan. With low test-retest reliability, the user cannot be confident in the ability of ICF coding to distinguish clinically meaningful change in heath-related states from measurement error. The ICF coding may have limited utility for classifying individual states of health, discriminating ICF health-related states between groups of people, or evaluating meaningful change over time. Might it not be more prudent to advocate the careful evaluation of the ICF Core Sets first to determine whether the ICF coding approach is psychometrically adequate for use in clinical practice? In the absence of psychometric evaluation, how can a clinician interpret the clinical relevance of the ICF Core Sets for use in physical therapist practice? A.M. Jette, PT, PhD, FAPTA, is Director, Health & Disability Research Institute, and Professor of Health Policy & Management, School of Public Health, Boston University, 580 Harrison Ave, 4th Floor, Boston, MA 02118 (USA). Address all correspondence to Dr Jette at: [email protected]. DOI: 10.2522/ptj.2009.0326.0327.ic

References 1 Escorpizo R, Stucki G, Cieza A, et al. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1054 –1063.

2 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland; World Health Organization; 2001. ¨ stu 3 Cieza A, Ewert T, U ¨ n B, et al. Development of ICF Core Sets for patients with chronic conditions. J Rehabil Med. July 2004(44 suppl):9 –11. 4 Rauch A, Escorpizo R, Riddle DL, et al. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther. 2010;90:1039 –1052. 5 Jette AM. Disablement models: toward a common language for function, disability, and health. Phys Ther. 2006;86:726 –734. 6 Jette AM. Toward a common language of disablement. J Gerontol A Biol Sci Med Sci. 2009;11:1165–1168. 7 Jette AM, Norweg A, Haley SM. Achieving meaningful measurements of ICF concepts. Disabil Rehabil. 2008;30:963–969. 8 Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil. 2003;25:628 – 634. 9 Steiner W, Ryser L, Huber E, et al. Use of the ICF model as a clinical problemsolving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002;82: 1098 –1107. 10 Peterson DB. International Classification of Functioning, Disability and Health: an introduction for rehabilitation psychologists. Rehabil Psychol. 2005;50:105–112. 11 Iezzoni LI, Greenberg M. Capturing and classifying functional status information in administrative databases. Health Care Financ Rev. 2003;24:61–76. 12 Kerlinger F. Foundations of Behavioral Research. New York, NY: Holt, Rinehart and Winston; 1973. 13 Nunnally JC, Bernstein IH. Psychometric Theory. New York, NY: McGraw-Hill; 1994. 14 Okochi J, Utsunomiya S, Takahashi T. Health measurement using the ICF: testretest reliability study of ICF codes and qualifiers in geriatric care. Health Qual Life Outcomes. 2005;3:46 –58.

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Commentary on the ICF and Physical Therapist Practice Reuben Escorpizo, Gerold Stucki, Alarcos Cieza, Alexandra Rauch, Daniel L. Riddle

Author Response We very much appreciate the commentary made by Jette1 on our articles.2,3 We see this exchange as part of an ongoing dialogue and debate regarding the use of the International Classification of Functioning, Disability and Health (ICF)4 by physical therapists. The World Health Organization (WHO) had a clear aim when it developed the ICF, and that is “to provide a unified and standard language and framework for the description of health and health-related states.”4 Specifically, this framework and language was meant to “code” the functioning of an individual and serve as a communication tool between and among health disciplines. The WHO also was clear that the ICF aims to serve as a scientific basis for the understanding of health and disability outcomes and determinants.4(pp3–5) These WHO guiding principles were the driving force behind our articles. In his commentary, Jette was explicit about the benefits of using the ICF, with prudent consideration of the aims above. He has made mention that the ICF as a conceptual framework and as a classification system is essential to and can positively affect physical therapist practice. At the same time, Jette pointed out the utility and methodological challenges that we face in using the ICF codes and its qualifiers. We recognize and agree with Jette that these limitations must be carefully examined with robust thinking and, most importantly, with sound science. Fundamentally, the ICF provides clinicians with “what” to measure (in a patient encounter) and a first practical approach about “how” to measure based on the ICF qualifiers. To answer the question of “how” to measure, new scientific-based pro1066

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posals have to be worked out in the near future. Users of the ICF are challenged to answer the question of “how” to measure when implementing this classification in clinical practice and research. However, the question of “what” to measure has to be answered first because it is fundamental to clinical practice. The ICF Core Sets, as a list of categories, provide the “what” to measure for a specific health condition or event. The combined use of an ICF Core Set and the ICF qualifier results in a “profile” of the patient. At this point, the question of how to arrive at a qualifier rating is up to the users and is not the question that was intended to be fully answered in our articles. Our primary intention was to comprehensively address the potential benefits of the Core Sets to efficiently identify what to measure. The use of the ICF Core Sets could alert the clinician to assess aspects of the patient’s daily life (eg, activities and participation) that otherwise would not have been documented without the categories provided by the Core Set.5 By providing the functioning profile of the patient, a comprehensive picture of the “lived experience” of the patient, including the magnitude of the problem in each functioning aspect, is captured and, thus, could be appropriately addressed in the intervention. The ICF Core Sets represent the domains that are relevant to a specific condition or event because, as Jette notes, the ICF Core Sets are based on evidence from the literature and with extensive input from the clinical and patient’s perspectives. Therefore, this gives the Core Sets, at the very least, face and content validity, which can both lend to the property of sensibility.6

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The ICF handbook is explicit that an ICF category as a code is most useful when a qualifier also is used (ie, 0 – 4 level of impairment).4(p21) Unfortunately, the qualifier in the ICF has limitations, which Jette eloquently addressed, and this is where concerns about psychometric quality become pronounced. Interrater reliability is an ongoing issue with the ICF qualifiers, with agreement of only up to moderate at best.7–10 Therefore, we agree with Jette that there is a strong need to improve the operational definition of the ICF category and to closely examine the measurement properties. More can be done to improve the definitions of ICF categories, such as combining category descriptions from the ICF handbook4 and developing a more specific instruction to better operationalize each category.11 This was the approach used in the most recent manual of the American Psychological Association.12 To measure an ICF category, 2 approaches have been proposed: (1) the ICF qualifiers, as indicated in our articles, can be used, or (2) when possible, scores or ratings from standard clinical tests or patient-reported instruments (eg, 100-mm visual analog scale for pain) can be used.11 If there are no validated instruments available for that ICF category, an ICF category interval scale can be created based on parts of a clinical test or some items of a questionnaire using advanced methods such as Rasch analysis.11,13 Specifically, items can be selected from validated measures that are linked to an ICF category, and an interval scale can be created as a way of operationalizing that ICF category.13 To measure across different ICF categories, condition-specific patient-reported measures that are Core Set based can July 2010

Commentary on the ICF and Physical Therapist Practice be used. Categories from an ICF Core Set also can serve as a basis for creating an aggregate scale.14 Work by Cieza and colleagues15 illustrates how a clinical measure based on the categories from ICF Core Set for osteoarthritis can be developed. The ICF provides a comprehensive list of domains from which clinicians can draw during patient assessment. For researchers, the ICF as a whole can be a “database” of domains that one can use to develop or integrate into instruments or measures.16 We agree with Jette that psychometrically sound instruments are needed to measure the various categories identified in ICF Core Sets, in particular, and in ICF, generally. This research effort should be given high priority, in our opinion. We also believe that there is value in using ICFbased Core Sets to identify the “what” to measure when examining patients. By using Core Sets, clinicians will be more likely to address the domains of health that are important in patients’ lives. We see no reason to forestall use of the ICF in daily practice until psychometrically sound instruments for all ICF categories are developed. Integrating currently available instruments with ICF categories and Core Sets will, in our opinion, advance practice.

References 1 Jette AM. Invited commentary on “Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice” and “Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management.” Phys Ther. 2010;90:1064 – 1065. 2 Escorpizo R, Stucki G, Cieza A, et al. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1053–1063. 3 Rauch A, Escorpizo R, Riddle DL, et al. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther. 2010;90:1039 –1052. 4 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 5 Pisoni C, Giardini A, Majani G, Maini M. International Classification of Functioning, Disability and Health (ICF) Core Sets for osteoarthritis: a useful tool in the follow-up of patients after joint arthroplasty. Eur J Phys Rehabil Med. 2008;44:377– 385. 6 Rowe BH, Oxman AD. An assessment of the sensibility of a quality-of-life instrument. Am J Emerg Med. 1993;11: 374 –380. 7 Hilfiker R, Obrist S, Christen G, et al. The use of the comprehensive International Classification of Functioning, Disability and Health Core Set for low back pain in clinical practice: a reliability study. Physiother Res Int. 2009;14:147–166. 8 Grill E, Mansmann U, Cieza A, Stucki G. Assessing observer agreement when describing and classifying functioning with the International Classification of Functioning, Disability and Health. J Rehabil Med. 2007;39:71–76.

9 Uhlig T, Lillemo S, Moe RH, et al. Reliability of the ICF Core Set for rheumatoid arthritis. Ann Rheum Dis. 2007;66:1078 – 1084. 10 Starrost K, Geyh S, Trautwein A, et al. Interrater reliability of the Extended ICF Core Set for Stroke applied by physical therapists. Phys Ther. 2008;88:841– 851. 11 Stucki G, Kostanjsek N, Ustun B, Cieza A. ICF-based classification and measurement of functioning. Eur J Phys Rehabil Med. 2008;44:315–328. 12 American Psychological Association. Procedural Manual and Guide for Standardized Application of the International Classification of Functioning, Disability and Health (ICF). Field Trial Version. Available at: www.apa.org. Accessed May 24, 2008. 13 Cieza A, Hilfiker R, Boonen A, et al. Items from patient-oriented instruments can be integrated into interval scales to operationalize categories of the International Classification of Functioning, Disability and Health. J Clin Epidemiol. 2009;62:912– 921, 921.e1–3. 14 Grill E, Stucki G. Scales could be developed based on simple clinical ratings of International Classification of Functioning, Disability and Health Core Set categories. J Clin Epidemiol. 2009;62:891– 898. 15 Cieza A, Hilfiker R, Chatterji S, et al. The International Classification of Functioning, Disability and Health could be used to measure functioning. J Clin Epidemiol. 2009;62:899 –911. 16 Osteras N, Brage S, Garratt A, et al. Functional ability in a population: normative survey data and reliability for the ICF based Norwegian function assessment scale. BMC Public Health. 2007;7:278.

DOI: 10.2522/ptj.2009.0326.0327.ar

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Perspective Closing the Gap Between Ethics Knowledge and Practice Through Active Engagement: An Applied Model of Physical Therapy Ethics Clare M. Delany, Ian Edwards, Gail M. Jensen, Elizabeth Skinner C.M. Delany, PhD, MHlth&MedLaw, MPhysio, BAppSciPhysio, is Senior Lecturer, Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Parkville 3010, Melbourne, Victoria, Australia, and Clinical Ethics Fellow, Children’s Bioethics Centre, Royal Children’s Hospital, Melbourne. Address all correspondence to Dr Delany at: [email protected]. I. Edwards, PhD, GradDipPhysio, BAppScPhysio, is Lecturer, School of Health Sciences, University of South Australia, Adelaide, Australia. G.M. Jensen, PT, PhD, FAPTA, is Dean of the Graduate School, Associate Vice President of Academic Affairs, Professor of Physical Therapy, and Faculty Associate, Center for Health Policy and Ethics, Creighton University, Omaha, Nebraska. E. Skinner, BPhysiotherapy(Hons), is Senior Physiotherapist, Intensive Care, Department of Physiotherapy, School of Health Sciences, The University of Melbourne.

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the “active engagement model,” is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

[Delany CM, Edwards I, Jensen GM, Skinner E. Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics. Phys Ther. 2010;90:1068 –1078.] © 2010 American Physical Therapy Association

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hysical therapists are rehabilitation experts who provide health services within health care dimensions of promotion, prevention, and intervention to people, communities, and populations.1,2 The physical therapy profession began as an adjunct to medical practice.3–5 This link extended to a reliance on the clinical and ethical decisions of the referring physician.6 With increasing professional autonomy and independence in clinical decision making and judgments, physical therapists face increasingly complex ethical issues in their professional practice.7 These ethical issues include understanding and balancing the needs of patients and those of the patients’ families and other professionals and working within the constraints and opportunities afforded by health policies and institutional systems and structures.7,8 In this context, physical therapists have moved away from a reliance solely on the medical profession to guide their ethics knowledge and decisionmaking frameworks. They have built their own body of literature about the nature and scope of ethics and ethical decision making in different areas of practice.9 –13 In this article, we identify the development and focus of ethics knowledge in physical therapy over the last several decades and highlight links and gaps between ethics knowledge as discussed in the literature and the specific ethical dimensions of physical therapist practice. We then propose an applied ethics model, titled the “active engagement model,” that seeks to integrate clinical and ethical dimensions of practice. Finally, we use that model to analyze a clinical ethics case scenario.

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Types and Dimensions of Ethics Knowledge in Physical Therapy In a comprehensive, retrospective analysis of physical therapy ethics knowledge from 90 English-language articles published between 1970 and 2000, Swisher14 found 2 broad approaches to defining and discussing ethics. Forty-three percent of the articles analyzed used a philosophical approach, defined by Swisher as a “concern with what people ought to do and how they ought to conduct themselves, as well as the rational basis for such decisions.”14(p694) Of these articles, 60% used biomedical principles as a guide to ethical behavior. Thirty-three percent of the articles used a social scientific or descriptive ethics approach, focusing on the exploration of human ethical behavior rather than on how people “ought” to behave. The remaining publications used a combination of historical development of codes of ethics and theoretical models of expertise in physical therapy (including moral virtue) to discuss ethics. Swisher’s 2002 review14 identified 3 main themes in the steady growth in the body of knowledge of ethics between 1970 and 2000: 1. 1970 –1979: establishing the role of the physical therapist as an ethical decision maker 2. 1980 –1989: applying philosophical principles to ethical problems 3. 1990 –2000: the evolving relationship between physical therapists and patients

In a follow-up to Swisher’s review, Carpenter and Richardson15 identified an additional 27 peer-reviewed articles about physical therapy ethics published between 2000 and 2007. Their review demonstrated a partial closing of the gap between theory and practice due to an increase in research about the “unique ethical issues encountered in physical therapy practice, factors that affect ethical action, the role of the physical therapists as a moral agent and the types of moral reasoning being used by physical therapists in practice.”15(p373) However, the authors again highlighted ongoing gaps about factors that influence everyday ethical decision making within specific contexts of physical therapist practice (Tab. 1).

Ethical Dimensions in Clinical Physical Therapist Practice Poulis16 recently discussed these theory-practice gaps in physical therapy, noting a degree of silence about the specific nature of physical therapist practice and any associated ethics scholarship. Poulis described 3 distinctive ethical issues that emerge from clinical physical therapist practice. These ethical issues derive from inherent goals and ideals of the physical therapy treatment encounter, the interdisciplinary nature of the clinical environment that requires decisions to be made about the best interests of patients within a web of health professional teams, institutional and health policies, and patient/family cultures and relationships.

However, the review also identified gaps in the physical therapy ethics knowledge base. Specifically, Swisher found that few studies had attempted to define the ethical issues that physical therapists routinely encounter in their everyday practice (Tab. 1). Volume 90

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Ethics Knowledge and Practice in Physical Therapy Table 1. Gaps in the Ethics Literature in Physical Therapy Key Findings

Gaps/Areas for Growth and Research

Swisher14

Author

Review of ethics articles (1970–2000) 1. Philosophical approach used by 43% of ethics articles analyzed, and 60% of these used biomedical principles 2. Social scientific/descriptive ethics approach

1. Sensitivity to the ethical dimensions of their clinical practice ● What are the ethical issues that physical therapists routinely encounter?14(p703) ● How does organizational context influence recognition and interpretation of ethical issues?14(p703) 2. Investigate the making of moral judgments ● What type of moral reasoning do physical therapists use?14(p703) ● What is the influence of sex, religion, or culture on moral judgments? 3. Uncover the influences on physical therapists’ abilities and motivation to act morally ● How do physical therapists view their role as a patient advocate? ● What factors (organizational, contextual, policy) affect physical therapists’ motivation for ethical action?

Carpenter and Richardson15

Review of ethics articles (2000–2007) 1. From 27 articles; increase in knowledge and research about unique ethical issues in physical therapy 2. Increased emphasis on moral agency and types of moral reasoning

1. How does the institutional setting affect the role of the physical therapist as a moral agent? 2. What are the cultural dimensions of ethical practice? 3. What are patients’ perspectives on ethical practice?

The first issue raised by Poulis16 concerns decision making about endpoints in physical therapy treatment in rehabilitative settings. Because a patient almost always can further improve with continuing physical therapy intervention, an appropriate endpoint for treatment may not be clear and the person responsible for deciding when the end of treatment occurs may not always be the physical therapist. Patients and other health care professionals may hold different definitions of end goals in rehabilitation.17,18 Thus, decisions to commence or cease physical therapy treatment might be made by the physical therapist or by an alternative health care professional, or the decision might be made on the basis of funding constraints and opportunities.19,20 Purtilo et al12(p41) defined these types of ethical issues as “locus of authority” problems. They include scenarios where a physical therapist, working within a multidisciplinary health care team, may not have the designated authority or moral agency to be able to achieve their discipline1070

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specific professional therapeutic goals and outcomes for the patient.17 Poulis’16 second ethical dimension of clinical practice concerns the often intimate and one-on-one interaction of physical therapy treatment, relying on touch, communication, advice, and at times, patient dependency. For example, patients with chronic illnesses,21,22 athletes who depend on being injury free for competition,23 and families who rely on ongoing management of their children with chronic conditions24 form close and personal relationships with their treating physical therapist. The nature of these types of relationships means that physical therapists need to be skilled in integrating and balancing their own therapeutic goals and purposes with those of their patients.22,25 This aspect of the patient/therapist relationship raises ethical issues concerned with recognizing and maintaining professional boundaries.26

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The third ethical dimension of clinical physical therapist practice highlighted by Poulis27 concerns the requirement for active participation of the patient and its impact on the patient/therapist relationship. Although trust is recognized as a crucial aspect of all health care practitioner relationships,28 in physical therapy, a patient’s trust must extend beyond accepting and believing in advice and treatment suggestions to a willingness to actively participate and collaborate to achieve the physical and functional goals set by his or her therapist.29 This means that physical therapy treatment methods and decisions encompass ideas associated with leadership, motivation, and promoting change in health behavior.30,31 These aspects of practice raise questions about associated ethical dimensions, such as: • What processes and methods of informing or persuading patients to achieve or participate in a desired therapeutic outcome are ethically appropriate?

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Ethics Knowledge and Practice in Physical Therapy • What model of shared decision making is the most relevant for therapists working with patients? • How do physical therapists incorporate ethical principles of trust, respect for autonomy, beneficence, and justice when setting goals with patients and formulating treatment strategies?

Linking Ethical and Clinical Dimensions of Physical Therapist Practice Two themes that arise from these descriptions and reviews of physical therapist practice and associated ethical dimensions are: connectedness and agency. In all aspects of physical therapist practice, there is a need to establish connections in the form of relationships with patients, patients’ families, other health care professionals, and institutions and organizations that externally fund or in some way influence the course of physical therapy treatment. Kyler25 described a relationship-centered approach to health care as one that captures the importance of interactions between people and social, political, economic, and environmental factors. In this article, we use the term “connectedness” to include this notion of interactive relationships and broaden it to extend to the web of associations and links between physical therapists and their discipline-based theoretical and practical approach to health care, their personal values, and the broader impact and influence of patients, health care colleagues, cultures, societies, institutions, and other health practices on physical therapist practice. The theme of “agency” arises from the need for physical therapists to work collaboratively with their patients and others while maintaining separate knowledge, motivation, and courage to engage as autonomous professionals with the moral

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aspects of their work.32 Benner et al referred to agency as the “ability to act upon or influence a situation.”33(p14) Agency to effect change in a patient or in others has links with notions of leadership,34 mindfulness,35 advocacy,32,36 and expertise.37 Agency requires a strong sense of self-awareness and an ability to be critically self-reflective.38

plement the decision. Moral agency in making ethical decisions, therefore, incorporates the ability to take from each side of the bridge, to make connections between ethical theory and practice, and to recognize the importance and influence of relationships built with patients, families, and other health care team members.

We have previously conceptualized these 2 themes that are derived from the clinical and ethical dimensions of physical therapist practice as moving between 2 sides of an ethical reasoning bridge.39 On one side of the bridge, a physical therapist (or other health care professional) draws from the connections he or she makes with a patient’s story to frame and recognize what seems to be ethically important. On the other side, the physical therapist draws from the meaning and philosophies found in the biomedical ethical principles and connects them with particular clinical contexts. Drawing from normative theory on one side and from patients’ perspectives and individual constructions of meaning about practice on the other side requires physical therapists to have a clear sense of their role and capacity to respond and act in clinical situations. This movement between general knowledge and analytical thinking on the one hand and the challenges of a particular situation on the other has been described as “practical reasoning.” Practical reasoning is done for a purpose, at a particular time, and in a particular situation.

An Applied Ethics Model: Active Engagement

This division of reasoning into practical, analytical, and theoretical forms derives originally from the work of Aristotle and has been reformulated by thinkers such as Dewey,40 Schon,41 and most recently, Sullivan.42 Importantly, drawing upon knowledge and understanding from either side of the bridge assumes a level of practical authority or agency to connect ideas, understand relationships, and then im-

The applied ethics model proposed in this article identifies an approach to ethical understanding and practice based on the themes of connectedness and agency in physical therapist practice. This model is grounded in the clinical work and education of physical therapists.1,2 It draws upon and synthesizes different sources of literature, including the use of established biomedical ethical principles,43,44 narrative theory,45– 48 and theories of sociology,13,49,50 to decrease the gap between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. The model has 3 practical components: (1) to listen actively, (2) to think reflexively, and (3) to reason critically. These 3 components have previously been described in physical therapy and other health care ethics literature as strategies and steps for gathering information and perspectives, identifying ethical issues, and generating appropriate practical responses.12,51 In our model, we have encapsulated these ideas into 3 practical steps that focus on the underlying skills, attitudes, and actions that are required to connect with people, systems, values, and structures and to build a sense of moral agency and purpose within physical therapists. Step 1: To Listen Actively Physical therapists spend much of their time communicating with and listening to patients and colleagues

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Ethics Knowledge and Practice in Physical Therapy as a standard part of their work. Our contention in this first practical step is that ethical analysis in physical therapist practice begins with an active listening approach. Active listening has many layers. It requires a commitment to the importance of telling and listening to stories as a way of discussing ethical issues. It requires some attentiveness to and curiosity about the details of other people’s stories. It also requires an awareness of how resources and their allocation affect peoples’ stories about providing and receiving health care. Associations between telling and listening to stories and ethical analysis have been made previously. Nelson52 defined narrative ethics or the telling of stories as a way of approaching clinical ethics, not just as a description of the key features of a clinical case or scenario but also as a means of achieving a moral end in itself. In telling or relating a story about an experience, a person makes sense of his or her life and experiences.47,53–56 For example, when a physical therapist tells a story about a clinical encounter, he or she implicitly or explicitly decides to portray himself or herself as a particular character with a sense of personal and moral agency. The therapist’s way of telling the story also provides information about how he or she perceives and understands other characters in their clinical story. Active listening in the ethics engagement model, therefore, is more than the exchange of information between the patient and therapist. It means listening closely to the patient’s perspective and story and being actively engaged in making connections between the patient’s circumstances, beliefs, values, and assumptions and the goals, values, resources, and actions of the therapist and of other people in the health care team. Both telling and listening 1072

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to stories also draws out the emotional aspects of health care practice.57,58 These aspects encourage practitioners to reflect on how their emotional reactions to patients’ stories and their own experiences can inform and facilitate reflection about ethical dimensions of practice.59 Active listening, therefore, means being alert to what Guillemin and Gillam referred to as “ethically important moments.”47(p7) These apparently mundane ethical experiences often encountered in ordinary clinical practice include moments of uncertainty about the right course of action, moments when there is a need to consider whether to speak up or not, moments when there is a recognition that a patient or a colleague needs support, and moments when there is a need to consider how and whether to persuade a patient to participate in an active treatment. Guillemin and Gillam47 used the label “sideways questions” to describe the types of questions that might facilitate active engagement with a story. Sideways questions go further than just relating the context, roles, and contributions in an abstract (formal case study, thirdperson) approach. The questions listed in Table 2 are based on these sideways questions. They aim to facilitate the consideration of broader aspects of physical therapists’ and their patients’ experiences to assist in identifying the ethically important dimensions of clinical treatment contexts. Step 2: To Think Reflexively The second step in the active engagement framework is to think about one’s own “physical therapy footprint” in the clinical scenario. Reflexivity and critical reflection are 2 related concepts that link to professional agency. Reflexivity means being aware of and paying attention to one’s own perspective and voice in a situation. The idea of reflexivity

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traditionally has been associated with paradigms of qualitative research60 – 62 but is increasingly recognized as important in health care practice.13,50 Guillemin and Gillam49 described reflexivity in qualitative research as a process involving critical reflection on how the researcher constructs knowledge from the research process. According to Patton,62(p65) it reminds researchers to be attentive to and conscious of “the cultural, political, social, linguistic, and ideological origins” of their own perspective and voice, the perspectives and voices of those they interview, and the perspectives of those to whom the research is reported. Applied to ethical decision making, reflexivity provides a means to increase awareness of one’s personal values, emotional reactions, and practices and how they might influence a patient’s reactions and choices.35,63 To make connections with others and to recognize ethical dimensions in their work, physical therapists need to be self-aware, reflexive, and mindful of their own unique contribution and identity as physical therapists in their care of patients. Without this understanding of the nature of their own practice or epistemological basis,39,64 their sense of agency and purpose and ways of connecting with others will be delivered in a professional vacuum. They will be less aware of how to make their connections with people and within institutions work toward achieving what is in the best interests of their patient. Within our model, the questions that we have developed to assist the reflective and reflexive process are listed in Table 2. Step 3: To Reason Critically To reason critically means to examine assumptions or presuppositions about practice and connections between oneself and social conJuly 2010

Ethics Knowledge and Practice in Physical Therapy Table 2. Active Engagement Model: Steps and Questions Steps

Facilitating Questions

Step 1: active listening

● ● ● ● ● ● ● ●

How has the patient and health care team member cast their story? Within the story, how do they portray themselves? Why are they telling the story in this way? Whose voice in the story is dominant? Whose voice in the story is not being heard? How else might this story have been told? What is ethically at stake in this story? What are the ethically important moments in the story?

Step 2: reflexive thinking

● ● ● ● ● ● ● ● ●

What goals and values do I, as the physical therapist, personally bring to a given treatment? What goals and values are inherent within the physical therapy treatment that I offer? What influence do my language and my treatment methods have on the patient and others? How do others (patients, colleagues, managers) know what they know? What shapes and has shaped their world view? How do they perceive me and why? How do I perceive them? How do they make sense of what I give them? What perspectives do they bring to the findings I offer?

Step 3: critical reasoning

Realm of patient and therapist relationship: ● What values and goals do I bring to the therapeutic relationship? ● How do my professional and personal values and goals differ from the patient’s? Organizational realm: ● What is my relationship with the health care organization? ● How does this relationship influence the clinical encounter? ● How do institutional systems and structures affect the patient’s ability to receive treatment? Societal realm: ● What are the health care structures, resources, and economic policies that influence the goals and provision of physical therapy?

texts.65– 67 Critical reasoning has been described as a key dimension of clinical reasoning, incorporating 4 main attributes and abilities: (1) reflecting and interpreting a clinical situation; (2) understanding the clinical context, including cultural values and facts; (3) engaging in an interactive and constructive dialogue with patients, peers, and mentors; and (4) integrating the influence of time through past experience, present contexts, and future actions.68 When applied as a component of the ethics engagement model, critical reasoning involves critical examination of the meaning and values of the 4 established biomedical ethical principles— beneficence, nonmaleficence, autonomy, and justice43— by asking questions about the meaning and scope of their relevance within the context of the clinical situation.44 It also means being cognizant of the nature and effect of the patient/therapist relationship within broader realms of the institution and July 2010

the broader cultural and societal influences on the provision of health care.8 The questions in Table 2 use Glaser’s8 categorization of different ethical realms to prompt a more critical examination of the micro and macro issues that affect clinical and ethical decision making.

Applying the “Active Engagement” Model to Sally’s Case We use a single physical therapy case study involving a patient with chronic neuropathy, as told by the physical therapist, Sally, to illustrate how the active engagement framework might be used to link ethics knowledge in theory to ethics in practice (Figure). All names in this case study are pseudonyms. At the time that this case occurred, Sally had 31⁄2 years of experience since graduation and worked as a junior physical therapist in a large metropolitan public hospital in a city in

Australia. She approached the primary author (C.M.D.) of this article to relate her personal clinical story. Sally then provided her informed consent to publish this version of her story. Specific ethical issues in Sally’s story include deciding how to communicate truth to patients and their families about diagnoses and prognoses, continuing with treatment when there is no evidence to support its effectiveness, dealing with different health care professionals’ views of what constitutes a patient’s best interests, and working within hierarchical organizations. Sally’s emotional responses expressed through the story include her feelings of frustration concerning professional relationships and conflicts between her values and those of the patient and her mother. In telling the story, Sally focuses on re-stating her beliefs about right actions and her justifications for those actions. When the active engagement model is used to analyze Sally’s responses, these

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Ethics Knowledge and Practice in Physical Therapy The patient, Cara, was a 28-year-old woman with a history of systemic lupus erythematosus, a chronic inflammatory disease and chronic inflammatory demyelinating neuropathy. Previous admissions (lasting for 16 months) had involved insertion of a percutaneous endoscopic gastrostomy feeding tube and tracheostomy. Many specialist units (including neurologists and rheumatologists) had consulted on Cara’s case, and no clear, agreed-upon diagnosis had been made to account for her varied, numerous, and severe symptoms. By the time Cara was admitted to our hospital, she had 90-degree flexion contractures of both elbows, bilateral knee flexion contractures, and bilateral plantar-flexion contractures in her ankles, along with minimal trunk, head, and neck control. Cara was fully dependent for all nursing and personal hygiene care. On admission, we (the treating team) had heard reports of how Cara’s mother, Sonia, had been very difficult for the staff at the previous hospital to deal with. We heard (as part of the handover) about how Sonia had insisted that one unit at the previous hospital had been forbidden to be involved in Cara’s care. We heard that Cara and Sonia were very difficult to deal with and were insisting on having family meetings all of the time and that they did not trust the medical staff. Already I felt uneasy about the information that gets passed around about a patient and the family before anybody at our hospital had even met them. At what point does handing over information to ensure the care of the patient is adequate become gossip that is not necessarily helpful to anybody, and how do you point that out to your colleagues in an appropriate manner? I was determined to get off to a good start with both Cara and her mother. During my assessment, it became quite clear to me that Cara’s physical situation was disastrous, but I was optimistic that I could make a difference to her. As soon as Sonia met me, she told me that she did not trust any of the physicians, that nobody knew what they were talking about, and that all of the physicians at the previous hospital (especially the neurologists and rheumatologists) had misdiagnosed Cara’s condition. Sonia told me that she had been doing some research on the Internet and had discovered that Cara had myopathy. Sonia was furious that Cara had been diagnosed with Guillain-Barre´ syndrome and neuropathy and insisted that myopathy was Cara’s main problem. Sonia further told me that she had found information on the American Medical Association Web site that the main or only treatment for myopathy was physical therapy. I explained to Sonia that there was a limited role for physical therapy in providing return of muscle function. I tried to give Sonia clear information about Cara’s condition from a physical point of view. I explained that until the nerves could transmit the signal better, we could only strengthen the muscle fibers that were

innervated, of which there were very few. I went into detail about the treatments I was trying and the rationale behind them. I explained that physical therapy, as a profession, really does not have any good peer-reviewed evidence for the treatment techniques that we were trying. I also made the point that the Internet is an unregulated source of information and that Sonia should not take for granted information that was accessed from the Internet. I felt good at the end of our conversation because Sonia seemed to take on board my key points. Sonia was pleasant to deal with, and it was clear to me that she only had her daughter’s best interests in mind. I consulted orthopedic and neurological physical therapists about the best way to try to treat Cara’s contractures. I grew frustrated because I was trying various treatments, few of which Cara could tolerate, and even fewer (ie, none) of which seemed to make a difference. I explained to both Cara and her mother that we needed to start to change the focus of treatment and that we would wind back the tilt table to only 3 times a week. I kept requesting that we hold a family meeting so that Cara and her family, particularly Sonia, could hear from several sources rather than just me about Cara’s poor physical prognosis. I also felt in a difficult situation in the physical therapy department because a physical therapist who was senior to me had covered my ward once or twice and had recommenced some treatments I had ceased. One afternoon, I received a page saying that I was being verbally attacked by Sonia in front of the whole ward round and that I should probably come up and defend myself. I felt upset that a layperson would question my professionalism in front of all of my colleagues. All of my colleagues (nursing, medical, and physical therapy staff) were very supportive after that ward round, but I would have loved to tell them that I would rather they were truthful to Cara and Sonia the whole time rather than nice to me when it all boiled over. In summary, I believe it is important to always try to communicate the truth to the patient and family, no matter how much they do not want to hear it—I believe it is our professional responsibility. I believe it is unethical to continue to provide treatments that are not working. I do not like feeling undermined, and I do not like feeling betrayed. If somebody has a problem with me, I would rather he or she told me in person without broadcasting it to the world while I am unaware of it. It is important to back your clinical judgment and have faith and trust in yourself. The health care system needs some serious revamping. Health care workers should never allow the patient and family to dictate the interaction—to be involved yes, but never to dictate. If I had the same situation again, I would do the same thing because ultimately I do not believe it helps anybody to hide the truth about a situation. Better frameworks to deal with emotional and mental and ethical stresses should be taught throughout the life span.

Figure. Sally’s story.

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Ethics Knowledge and Practice in Physical Therapy Table 3. Questions For and Answers From Sally Questions for Sally

Answers

1. How has the story been cast?

The focus of my story is on my analysis of my reactions and responses to the clinical scenario.

2. How has Sally, in telling the story, portrayed herself?

I cast myself as having good therapeutic intentions, including being determined to bring about a change where others had clearly had difficulty in the past.

3. Why is Sally telling the story in this way?

I wanted to justify my position and decisions about the treatment and the conflict surrounding the treatment.

4. Whose voice in the story is dominant?

My voice is dominant.

5. Whose voice in the story is not being heard?

Cara’s voice is not present in the telling of this story. Sonia’s voice, as the mother, is overbearing and strident. Other health care colleagues are cast as passive players in the story.

6. How else might this story have been told?

The story could have been told from the perspective of Cara, her mother, or other members of the treating team.

7. What is ethically at stake in this story?

How to define futility in long-term rehabilitation care. How to negotiate differences in values and beliefs about health care among patients, patients’ family members, and physical therapists. Defining the scope and limitations of professional autonomy. The influence of both collegiality and diversity in professional health care approaches on patient outcomes. The rights of competent adult patients to decide their health care.

8. What are the ethically important moments?

When Sally first wondered about the information conveyed about Cara and her mother at handover. When Sally felt uncomfortable about how much information she should convey to Cara and her mother. When Sally reflected on the futility of the treatment. When Sally felt she was not supported by her colleagues.

ethical issues are broadened to include a richer and broader range of considerations to provide insight and guidance for Sally in this situation and for future similar clinical scenarios. Step 1: To Listen Actively Step 1 of the active engagement model requires active listening and active engagement with Sally’s story. Table 3 lists the questions and Sally’s responses to this first step. Step 2: To Think Reflexively The aims of the reflexive questions in step 2 are to expand the perspectives and understanding of the clinical situation and to provide opportunities to engage with other people’s possible stories rather than focus only on presenting a coherent and justified view of one’s own actions. When Sally responded to the reflexive and reflective questions in step 2 of the framework, she began to consider the goals and values that she July 2010

had brought to the encounter, not just as a means of justifying her decision or her rationale for refusing treatment but also as a way of examining how they intersect with and influence the goals and values held by the patient, “Cara,” and her mother, “Sonia.” Sally stated that her overriding goals at the time were to “communicate clear and accurate information regarding physical capacity and prognosis” and to ensure that her patient “should be in a position to make an informed decision.” Sally did not believe that “laypeople using the Internet” was a source of accurate information, comparable with analysis of peer-reviewed literature. On further reflection about how these values intersected with those of her patient, Sally stated: My language and treatment methods (as a junior and developing clinician) were very self-focused. That would certainly influence both Sonia’s and Cara’s responses to me if they per-

ceived that I was not as interested in their perspectives as I was my own. . . . I think that I could have considered that nursing and medical staff and my colleagues knew what they knew from clinical experience (in the main); however, none of these people (nor I) were particularly good at communicating how we knew what we knew and sharing information or discussing these perspectives openly.

Sally also used the reflexive questions to start to analyze, from a critical perspective, how others might have perceived her reactions, responses, and views. Step 3: To Critically Reason In this step, Sally considered and evaluated the meaning of the biomedical ethical principles and how they applied to her story. For example, when considering the most beneficial treatment for Cara, Sally questioned the meaning of beneficence for someone in Cara’s situation. At the time, Sally believed that the most

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Ethics Knowledge and Practice in Physical Therapy appropriate treatment for Cara was one that had demonstrated efficacy, that is, be defined only with reference to published evidence. Sally was also prompted to consider the impact of her role as an employee of a large metropolitan hospital. Her reflections highlight the duties she owed to her physical therapy department; relevant policies and procedures about patient care, and the existing hierarchies within the institution’s professional team: My relationship with the health care organization was developing and in its infancy. I perhaps did not speak up as early or as much as perhaps was required (for a series of reasons), including a perception that more senior colleagues knew better, and . . . I was somewhat intimidated by the respiratory consultants and more broadly by the hierarchy of the hospital system.

Implications for Practice and Education Using the active engagement framework opens up different questions and considerations. In Sally’s story, it leads to thinking about: 1. The goals of physical therapy in chronic and degenerative conditions. 2. The “sandwich” role sometimes played by physical therapists in providing rehabilitative treatment (ie, sandwiched between a need to meet the patient’s needs as recognized by the patient and needing to meet the goals of other members of the health team). Varcoe and Rodney,69 writing for nurses, labeled this “constrained moral agency,” where constraints or barriers to acting in what they might see as the patient’s best interests are formed by interests of the others involved in their care and health care decision making. For physical therapists, Carpenter70 used the term “moral distress” to describe the experience 1076

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of being unable to achieve the desired outcomes for clients within complex health care environments. 3. The idea of professional boundaries and ideals of practice. How much treatment should physical therapists offer when there are no strict boundaries around rehabilitation treatment? Who should decide the scope and nature of physical therapy services for these patients—the patient, the family, colleagues? 4. How to optimize communication among health care colleagues within large public hospitals. How can physical therapists enhance that communication? In Sally’s words, after telling and reflecting upon this story: I have an enhanced perspective of the health care system and the influences and perspectives of various bodies (including system, organization, team, family, other staff members, and the patient) on the therapeutic interaction, including relationships between myself and Cara (and Sonia). Working through the framework allowed me to realize that there are multiple strategies that I can incorporate and multiple ways of dealing with ethical issues as they arise. Ideally, this would equip clinicians with the tools to more comfortably work with these “ethically challenging or important moments” and be less intimated by them and to see them as an opportunity to inform their clinical or therapeutic interaction and development, and not least to improve their ability to deliver optimal patient care in the setting within which they work.

The outcome of telling and thinking about Sally’s story does not immediately present a solution in terms of ethical actions. The practical outcome is not limited to using ethical reasoning to justify the application of biomedical ethical principles. In-

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stead, it facilitates more active engagement with ethical issues by acknowledging and questioning values, emotions, guiding ethical principles, and systems and procedures that affect provision of care. The end result of using the active engagement model is to generate a bigger list of smaller or more everyday ethical issues that arise in clinical practice. Using the tenets of narrative reasoning, it involves the generation of hypotheses related to the particular details of a situation or person’s experience.33 The model also works toward integrating both normative (philosophical) and empirical (facts and experiences) dimensions of ethics in clinical practice.14 Heightened awareness of “ethically important moments”49 means that the next time Sally finds herself in the position of dealing with a patient whose values about health and whose interpretations of benefit differ from her own, she may remember what she previously learned by the telling and reflecting on what was important in this story. It may lead her to raise the issue earlier within her own department—that is, how to deal with a patient who demands treatment that is not considered to be beneficial and to seek opinions from other physical therapists. Sally may speak earlier to the consultants and physicians involved in the patient’s care to more explicitly establish roles and expectations within the team. Sally may think about the limits of physical therapy treatment and review the goals of treatment to be more realistic in similar treatment situations. In addition, as she becomes a more experienced clinician, this method of active engagement will enhance her ability to consider the perspectives of the patient, the family, and the treating team, as well as to be cognizant of the influence of the broader hospital system. Sally may seek support from July 2010

Ethics Knowledge and Practice in Physical Therapy colleagues much earlier and be more comfortable discussing and sharing ethically important moments with others.

Conclusion Emerging literature in physical therapy13,39,71 and in health care more generally8,11,16,53,72,73 suggests gaps between knowledge of ethical theory and its implementation in practice. These considerations point to a need for a more applied approach to ethics in clinical practice, that is, one that draws from everyday clinical situations, including identifying practical opportunities for and constraints to acting ethically. In this article, we have proposed a model of applied ethics based on current ethics scholarship and the distinctive features of physical therapy clinical practice. In order to refine this model, more research is needed about the nature and scope of ethical issues in physical therapist practice and how physical therapists respond as moral agents in their everyday practice. Our model posits that telling, listening to, and questioning stories about clinical practice experiences provides a first step in illuminating both obvious and hidden ethical perspectives in physical therapy work. It provides a link between ethical theories and knowledge and physical therapists’ experiences of ethics in practice. Reflecting on stories reflexively and critically adds a further dimension to understanding ethical issues. Importantly, it provides a method for physical therapists to learn the processes necessary for developing moral agency within their day-to-day practice. Dr Delany, Dr Edwards, and Dr Jensen provided concept/idea/project design. Dr Delany and Dr Skinner provided data collection and analysis. Dr Delany provided project management. All authors provided writing

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and consultation (including review of manuscript before submission). This article was submitted November 14, 2009, and was accepted March 21, 2010. DOI: 10.2522/ptj.20090379

References 1 Higgs J, Refshauge K, Ellis E. Portrait of the physiotherapy profession. J Interprof Care. 2001;15:79 – 89. 2 Higgs J, Smith M, Webb G, Skinner M, eds. Contexts of Physiotherapy Practice. Sydney, Australia: Elsevier; 2008. 3 Carpenter C. The evolving culture of physiotherapy. Physiother Can. 1996;48:11–15. 4 Linker B. The business of ethics: gender, medicine, and the professional codification of the American Physiotherapy Association, 1918 –1935. J Hist Med Allied Sci. 2005;60:320 –354. 5 Stachura K. Professional dilemmas facing physiotherapists. Physiotherapy. 1994;80: 357–360. 6 Clawson AL. The relationship between clinical decision making and ethical decision making. Physiotherapy. 1994;80:10 –14. 7 Anderson L, Ellis E. Ethics, practice regulation and physiotherapy. In: Higgs J, Smith M, Webb G, et al, eds. Contexts of Physiotherapy Practice. Sydney, Australia: Elsevier; 2009:177–188. 8 Glaser J. Three realms of ethics: an integrating map of ethics for the future. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005: 169 –184. 9 Delany CM. Respecting patient autonomy and obtaining their informed consent: ethical theory—missing in action. Physiotherapy. 2005;91:197–203. 10 Delany CM. In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study. Aust J Physiother. 2007; 53:171–177. 11 Edwards I, Braunack-Mayer A, Jones M. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy. 2005;91:229 –236. 12 Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005. 13 Jensen GM. Mindfulness: applications for teaching and learning in ethics education. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005: 191–202. 14 Swisher LL. A retrospective analysis of ethics knowledge in physical therapy (1970 – 2000). Phys Ther. 2002;82:692–706. 15 Carpenter C, Richardson B. Ethics knowledge in physical therapy: a narrative review of the literature since 2000. Phys Ther Rev. 2008;13:366 –374.

16 Poulis I. Bioethics and physiotherapy. J Med Ethics. 2007;33:435– 436. 17 Flett PJ, Stoffell BF. Ethical issues in paediatric rehabilitation. J Paediatr Child Health. 2003;39:219 –223. 18 Gibson BE, Darrah J, Cameron D, et al. Revisiting therapy assumptions in children’s rehabilitation: clinical and research implications. Disabil Rehabil. 2009;31: 1446 –1453. 19 Purtilo RB. Managed care: ethical issues for the rehabilitation professions. Trends Health Care Law Ethics. 1995;10(1–2): 105–108, 118. 20 Thomasma DC. The ethics of managed care: challenges to the principles of relationship-centered care. J Allied Health. 1996;25:233–246. 21 Baker J, Stiller K. Chronic illness: a view from the other side. Aust J Physiother. 2006;52:155–156. 22 Latimer J, Maher C, Refshauge K. The attitudes and beliefs of physiotherapy students to chronic back pain. Clin J Pain. 2004;20:45–50. 23 McKenna J, Delaney H, Phillips S. Physiotherapists’ lived experience of rehabilitating elite athletes. Phys Ther Sport. 2002; 3:66 –78. 24 Carnevale FA, Alexander E, Davis M, et al. Daily living with distress and enrichment: the moral experience of families with ventilator-assisted children at home. Pediatrics. 2006;117:e48 – e60. 25 Kyler P. The ethics of client-centered care models. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005:159 –167. 26 Cooper I, Jenkins S. Sexual boundaries between physiotherapists and patients are not perceived clearly: an observational study. Aust J Physiother. 2008;54: 275–279. 27 Poulis I. The end of physiotherapy. Aust J Physiother. 2007;53:71–72. 28 O’Neill O. Autonomy and Trust in Bioethics. Cambridge, United Kingdom: Cambridge University Press; 2004. 29 Parry RH. Communication during goalsetting in physiotherapy treatment sessions. Clin Rehabil. 2004;18:668 – 682. 30 Bass BM, Steidlmeier P. Ethics, character, and authentic transformational leadership behaviour. The Leadership Quarterly. 1999;10:181–217. 31 Buchanan D. Moral reasoning as a model for health promotion. Soc Sci Med. 2006; 63:2715–2726. 32 Davis C. Educating adult health professionals for moral action: in search of moral courage. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005:215–224. 33 Benner P, Hooper-Kyriakidis P, Stannard D. Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach. Philadelphia, PA: WB Saunders Co; 1999.

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Ethics Knowledge and Practice in Physical Therapy 34 Chervenak FA, McCullough LB. The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient. Am J Obstet Gynecol. 2001;184:875– 880. 35 Jensen GM, Richert A. Reflections on the teaching of ethics in physical therapist education: integrating cases, theory and learning. J Phys Ther Educ. 2005;19: 78 – 85. 36 Hewitt J. A critical review of the arguments debating the role of the nurse advocate. J Adv Nurs. 2002;37:439 – 445. 37 Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80:28 – 43. 38 Delany CM, Watkin D. A study of critical reflection in health professional education: “learning where others are coming from.” Adv Health Sci Educ Theory Pract. 2009;14:411– 429. 39 Edwards I, Delany CM. Ethical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. 3rd ed. Boston, MA: Elsevier; 2008:279 –289. 40 Dewey J. How We Think: A Restatement of the Relation of Reflective Thinking to the Educative Process. Boston, MA: DC Heath & Co; 1933. 41 Schon D. Educating the Beginning Practitioner. San Francisco, CA: Jossey-Bass; 1987. 42 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. San Francisco, CA: Jossey-Bass; 2005. 43 Beauchamp T, Childress J. Principles of Biomedical Ethics. 5th ed. Oxford, United Kingdom: Oxford University Press; 2001. 44 Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;909: 184 –188. 45 Adams TE. A review of narrative ethics. Qual Inquiry. 2008;14:175–194. 46 Brody H. Stories of Sickness. New York, NY: Oxford University Press; 2003. 47 Guillemin M, Gillam L. Telling Moments: Everyday Ethics in Health Care. Melbourne, Australia: IP Communications; 2006. 48 Kleinman A. What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. Oxford, United Kingdom: Oxford University Press; 2006.

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62 Patton M. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, California: Sage Publications; 2002. 63 Wessel J, Larin H. Change in reflections of physiotherapy over time in clinical placements. Learn Health Soc Care. 2006;5: 119 –132. 64 Richardson B, Higgs J, Dahlgren M. Recognising practice epistemology in the health professions. In: Higgs J, Richardson B, Dahlgren M, eds. Developing Practice Knowledge for Health Professionals. Edinburgh, Scotland: Butterworth Heinemann; 2004:1–14. 65 Brookfield S. Becoming a Critically Reflective Teacher. San Francisco, CA: JosseyBass; 1995. 66 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. San Francisco, CA: Jossey-Bass; 2005. 67 Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey Bass; 1991. 68 Christensen N, Jones M, Higgs J, Edwards I. Dimensions of clinical reasoning capability. In: Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. Amsterdam, the Netherlands: Butterworth Heinemann 2008: 101–110. 69 Varcoe C, Rodney P. Constrained agency: the social structure of nurses’ work. In: Bolaria B, Dickinson H, eds. Health, Illness and Health Care in Canada. Toronto, Ontario, Canada: Nelson; 2002. 70 Carpenter C. Moral distress in physical therapy practice. Physiother Theory Pract. 2010;26:69 –78. 71 Mostrom E. Teaching and learning about the ethical and human dimensions of care in clinical education: exploring student and clinical instructor experiences in physical therapy. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005:265–284. 72 Jensen GM, Paschal K. Habits of mind: student transition toward virtuous practice. J Phys Ther Educ. 2000;14:42– 47. 73 Lucius-Hoene G. Illness narratives and narrative medicine. Rehabilitation (Stuttg). 2008;47:90 –97.

E. Lynne Geddes

Applying ethical reasoning within clinical practice is crucial to holistic patient care. In their article, Delany et al1 use insights from 2 retrospective analyses of physical therapy ethics knowledge2,3 as the springboard for their applied model of physical 1078

49 Guillemin M, Gillam L. Ethics, reflexivity, and “ethically important moments” in research. Qual Enquiry. 2004;10:261–280. 50 Taylor C, White S. Practicing Reflexivity in Health and Welfare. Buckingham, United Kingdom: Open University Press; 2000. 51 Kerridge I, Lowe M, McPhee J. Ethics and Law for the Health Professions. 2nd ed. Sydney, Australia: Federation Press; 2005. 52 Nelson H. Introduction. In: Nelson H, ed. Stories and Their Limits: Narrative Approaches to Bioethics. New York, NY: Routledge; 1997. 53 Guillemin M, Gillam L. Ethical mindfulness: narrative analysis and everyday ethics in health care. Adv Med Sociol. 2008; 9:159 –180. 54 Nelson HL. Context: backward, sideways and forward. In: Charon R, Montello M, eds. Stories Matter: The Role of Narrative in Medical Ethics. New York, NY: Routledge; 2002. 55 Nelson HL. Moral teachings from unexpected quarters: lessons for bioethics from the social sciences and managed care. Hastings Cent Rep. 2000 30:12–17. 56 Greenhalgh T. What Seems to Be the Trouble: Stories in Illness and Healthcare. Oxford, United Kingdom: Radcliffe Publishing; 2006. 57 Goldie P. Narrative and perspective: values and appropriate emotions. In: Hatzimoysis A, ed. Philosophy and the Emotions. Cambridge, United Kingdom: Cambridge University Press; 2003. 58 Shapiro J, Rucker L, Boker J, Lie D. Pointof-view writing: a method for increasing medical students’ empathy, identification and expression of emotion, and insight. Educ Health (Abingdon). 2006;19: 96 –105. 59 Lemonidou C, Papathanassoglou E, Giannakopoulou M, et al. Moral professional personhood: ethical reflections during initial clinical encounters in nursing education. Nurs Ethics. 2004;11:122–137. 60 Barry C, Britten N, Barber N, et al. Using reflexivity to optimise teamwork in qualitative research. Qual Health Res. 1999;9: 26 – 44. 61 Hansen E. Successful Qualitative Health Research. Sydney, Australia: Allen & Unwin; 2006.

therapy ethics. Both Swisher2 and Carpenter and Richardson3 identified gaps that exist between ethics knowledge and clinical practice. Hence, Delany et al1 propose a model to close this gap. The article concludes by applying the model to

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a clinical scenario to assist the reader in exploring its application. This discussion is timely within the profession. As a registered physical therapist in Ontario, Canada, my College of Physiotherapists of Ontario4,5 July 2010

Ethics Knowledge and Practice in Physical Therapy 34 Chervenak FA, McCullough LB. The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient. Am J Obstet Gynecol. 2001;184:875– 880. 35 Jensen GM, Richert A. Reflections on the teaching of ethics in physical therapist education: integrating cases, theory and learning. J Phys Ther Educ. 2005;19: 78 – 85. 36 Hewitt J. A critical review of the arguments debating the role of the nurse advocate. J Adv Nurs. 2002;37:439 – 445. 37 Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80:28 – 43. 38 Delany CM, Watkin D. A study of critical reflection in health professional education: “learning where others are coming from.” Adv Health Sci Educ Theory Pract. 2009;14:411– 429. 39 Edwards I, Delany CM. Ethical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. 3rd ed. Boston, MA: Elsevier; 2008:279 –289. 40 Dewey J. How We Think: A Restatement of the Relation of Reflective Thinking to the Educative Process. Boston, MA: DC Heath & Co; 1933. 41 Schon D. Educating the Beginning Practitioner. San Francisco, CA: Jossey-Bass; 1987. 42 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. San Francisco, CA: Jossey-Bass; 2005. 43 Beauchamp T, Childress J. Principles of Biomedical Ethics. 5th ed. Oxford, United Kingdom: Oxford University Press; 2001. 44 Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;909: 184 –188. 45 Adams TE. A review of narrative ethics. Qual Inquiry. 2008;14:175–194. 46 Brody H. Stories of Sickness. New York, NY: Oxford University Press; 2003. 47 Guillemin M, Gillam L. Telling Moments: Everyday Ethics in Health Care. Melbourne, Australia: IP Communications; 2006. 48 Kleinman A. What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. Oxford, United Kingdom: Oxford University Press; 2006.

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62 Patton M. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, California: Sage Publications; 2002. 63 Wessel J, Larin H. Change in reflections of physiotherapy over time in clinical placements. Learn Health Soc Care. 2006;5: 119 –132. 64 Richardson B, Higgs J, Dahlgren M. Recognising practice epistemology in the health professions. In: Higgs J, Richardson B, Dahlgren M, eds. Developing Practice Knowledge for Health Professionals. Edinburgh, Scotland: Butterworth Heinemann; 2004:1–14. 65 Brookfield S. Becoming a Critically Reflective Teacher. San Francisco, CA: JosseyBass; 1995. 66 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. San Francisco, CA: Jossey-Bass; 2005. 67 Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey Bass; 1991. 68 Christensen N, Jones M, Higgs J, Edwards I. Dimensions of clinical reasoning capability. In: Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. Amsterdam, the Netherlands: Butterworth Heinemann 2008: 101–110. 69 Varcoe C, Rodney P. Constrained agency: the social structure of nurses’ work. In: Bolaria B, Dickinson H, eds. Health, Illness and Health Care in Canada. Toronto, Ontario, Canada: Nelson; 2002. 70 Carpenter C. Moral distress in physical therapy practice. Physiother Theory Pract. 2010;26:69 –78. 71 Mostrom E. Teaching and learning about the ethical and human dimensions of care in clinical education: exploring student and clinical instructor experiences in physical therapy. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005:265–284. 72 Jensen GM, Paschal K. Habits of mind: student transition toward virtuous practice. J Phys Ther Educ. 2000;14:42– 47. 73 Lucius-Hoene G. Illness narratives and narrative medicine. Rehabilitation (Stuttg). 2008;47:90 –97.

E. Lynne Geddes

Applying ethical reasoning within clinical practice is crucial to holistic patient care. In their article, Delany et al1 use insights from 2 retrospective analyses of physical therapy ethics knowledge2,3 as the springboard for their applied model of physical 1078

49 Guillemin M, Gillam L. Ethics, reflexivity, and “ethically important moments” in research. Qual Enquiry. 2004;10:261–280. 50 Taylor C, White S. Practicing Reflexivity in Health and Welfare. Buckingham, United Kingdom: Open University Press; 2000. 51 Kerridge I, Lowe M, McPhee J. Ethics and Law for the Health Professions. 2nd ed. Sydney, Australia: Federation Press; 2005. 52 Nelson H. Introduction. In: Nelson H, ed. Stories and Their Limits: Narrative Approaches to Bioethics. New York, NY: Routledge; 1997. 53 Guillemin M, Gillam L. Ethical mindfulness: narrative analysis and everyday ethics in health care. Adv Med Sociol. 2008; 9:159 –180. 54 Nelson HL. Context: backward, sideways and forward. In: Charon R, Montello M, eds. Stories Matter: The Role of Narrative in Medical Ethics. New York, NY: Routledge; 2002. 55 Nelson HL. Moral teachings from unexpected quarters: lessons for bioethics from the social sciences and managed care. Hastings Cent Rep. 2000 30:12–17. 56 Greenhalgh T. What Seems to Be the Trouble: Stories in Illness and Healthcare. Oxford, United Kingdom: Radcliffe Publishing; 2006. 57 Goldie P. Narrative and perspective: values and appropriate emotions. In: Hatzimoysis A, ed. Philosophy and the Emotions. Cambridge, United Kingdom: Cambridge University Press; 2003. 58 Shapiro J, Rucker L, Boker J, Lie D. Pointof-view writing: a method for increasing medical students’ empathy, identification and expression of emotion, and insight. Educ Health (Abingdon). 2006;19: 96 –105. 59 Lemonidou C, Papathanassoglou E, Giannakopoulou M, et al. Moral professional personhood: ethical reflections during initial clinical encounters in nursing education. Nurs Ethics. 2004;11:122–137. 60 Barry C, Britten N, Barber N, et al. Using reflexivity to optimise teamwork in qualitative research. Qual Health Res. 1999;9: 26 – 44. 61 Hansen E. Successful Qualitative Health Research. Sydney, Australia: Allen & Unwin; 2006.

therapy ethics. Both Swisher2 and Carpenter and Richardson3 identified gaps that exist between ethics knowledge and clinical practice. Hence, Delany et al1 propose a model to close this gap. The article concludes by applying the model to

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a clinical scenario to assist the reader in exploring its application. This discussion is timely within the profession. As a registered physical therapist in Ontario, Canada, my College of Physiotherapists of Ontario4,5 July 2010

Ethics Knowledge and Practice in Physical Therapy instituted a revised Code of Ethics and Standards for Professional Ethics in October 2009. The revised American Physical Therapy Association (APTA) Code of Ethics for the physical therapist and Standards of Ethical Conduct for the Physical Therapist Assistant take effect July 1, 2010.6 The profession’s evolution has been influenced by increased complexity, enhanced professional autonomy, expanded scope of practice, direct access,1,7 and interprofessional collaboration. These factors are present across health care delivery systems, jurisdictional boundaries, and professional contexts and will continue to challenge the profession and individual physical therapists. As a result, the application of ethical decision making in everyday practice is essential. Two relevant purposes for codes of ethics, described in the literature, delineate: (1) the responsibilities of the individual and (2) the accountability to the broader community. They have been described as “fostering a ‘moral self-understanding,’ and creating a professional moral community”7(p804) or as “educating and providing guidance to members of the profession [in ethical decision making and conduct]; and promoting the ‘social contract,’ public accountability, and societal expectations.”7(p804) Conceptually, these purposes resonate with the 2 themes of agency and connectedness expressed by Delany et al.1 Agency articulates the roles and obligations of the autonomous practitioner in his or her ability to affect a situation. It means being “capable of deliberating, thinking, deciding, and acting in accordance with personal and professional moral standards and principles.”8(p69) Connectedness describes the interrelationships among all parties with whom therapists interact to provide care. It can be conceptualized, as stated above, in terms of a social conJuly 2010

tract. However, a “contract” often is viewed as prescriptive. Other authors have used terms such as “covenant” or “communion.” The term “covenant” embodies commitment, empathy, and creativity,9 and the term “communion” implies caring and togetherness.10 Agency and connectedness are significant features underpining moral action. When studying the moral personality of brave exemplars (recipients of the Canadian Medal of Bravery) and caring exemplars (recipients of the Caring Canadian Award) and matched comparisons, Walker and Frimer10 found that both groups of exemplars demonstrated stronger personality variables of agency and communion than comparison groups (P⬍.001). The active engagement applied ethics model is grounded in the themes of agency and connectedness. I infer from Delany and colleagues’ description1 that their model is intended to reframe more “traditional” ethical decision-making models. As such, they have distilled more complex or detailed models into 3 simple components: to listen actively, to think reflexively, and to reason critically. Furthermore, these steps resonate with 3 core components of the clinical decision-making process. However, the model is not simplistic. It presupposes engagement and, by distilling complexity into simplicity, implies the need for a sound understanding of ethics by the practitioner. Both of these characteristics are essential for integrating ethical and clinical decision making.8 For me, there are 3 important requirements for the type of engagement that is central to implementing this model: moral sensitivity, moral imagination, and moral courage. Moral sensitivity was described by Rest in his Four Component Model as “the awareness of how our actions affect other people”11(p23) and implies an ability to interpret a situation. Without moral

sensitivity, a physical therapist may not identify an ethical situation and cannot thoughtfully engage in the 3 steps of the model. Moral imagination includes being able to put oneself in the place of others and to envisage various ways of acting in the situation,12 perhaps what Delany et al1 meant as curiosity. These are important features for active listening (step 1) and critical reasoning (step 3). Moral courage gives the physical therapist the ability to act, often in the face of fear or other barriers.13 Moral courage also been described by Rest11 as moral character. In my reading of this model, carrying through with the selected course of action is not explicitly included in the 3 steps. More recently, these 3 concepts— moral sensitivity, moral imagination, and moral courage— have been encapsulated by Weaver et al in their definition of ethical sensitivity: Ethical sensitivity is the capacity to decide with intelligence and compassion, given uncertainty in a care situation, drawing as needed on a critical understanding of codes of ethical conduct, clinical experience, academic learning and self knowledge, with an additional ability to anticipate consequences and the courage to act.14(p610)

They caution that if a practitioner is “merely doing a job, if others must point out the presence of an ethical issue. . .if professionals are certain that they know in advance what is morally right to do, or if professionals address situations as solely technical,”14(p612) ethical sensitivity is absent. I would argue it also would preclude a physical therapist from having the capacity to apply the active engagement model. This model moves away from the direction taken in the revised APTA Code of Ethics. In revising the Code of Ethics, there was a shift away from stating a few general principles to using an expanded format detailing

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Ethics Knowledge and Practice in Physical Therapy the actions required by the physical therapist to achieve a given principle.7 Without including expanded detail, a code of ethics may be too vague7 to be useful. Swisher and Hiller stated, The primary arguments advanced for the expanded format of the documents were the educational value of more specific guidance for physical therapists and physical therapist assistants, the enhanced public accountability of published consistent normative standards of conduct, and the opportunity for the membership and their representatives in the [House of Delegates] to have greater input into ongoing dialogue about ethical matters.7(pp814 – 815)

Interestingly, the College of Physiotherapists of Ontario,4 in revising its Code of Ethics, took the opposite approach. The College moved from a prior code with specification to an acronym (Respect, Excellence, Autonomy and well being, Communication, collaboration and advocacy, Honesty and integrity) supported by overarching principles and educational modules. It could be argued that, in addition to presupposing a level of ethical sensitivity, the 3 steps in the active engagement model are too general to be useful. Perhaps to overcome this, Delany et al1 explicitly or implicitly incorporate 3 adjuncts to support the model’s implementation. First, they augment each step of the active engagement model with facilitating questions (their Tab. 2). The questions help the physical therapist delve into the intended scope of each of the 3 steps. Second, they utilize the richness of a narrative. By using stories, poems, and even theatre, health care professionals discover the issues and the people embedded in the narrative, infusing reasoning with mindfulness.15,16 Delany et al1 use Sally’s story to bring alive their active engagement model 1080

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for the reader and reveal the power of personal written narrative. Finally, Sally, a clinician for 31⁄2 years, approached Dr Delany, a known expert in ethics, to relate her story. This demonstrates the benefit of a mentor to help work through difficult ethical and clinical situations and the influence of the different characteristics of novice and expert clinicians on clinical reasoning.17 The interface between professional knowledge and ethical values defines clinical practice.18 Delany et al1 are to be commended for seeking to bridge this interface by describing and applying their active engagement model. I hope that their article, in the context of current practice and the implementation of the revised ATPA ethics documents, stimulates lively discussion. Although the profession has morally matured, this journey must continue. As autonomous practitioners, we have an obligation to take seriously our role as moral agents. As educators, we need to provide learning opportunities for both pre- and post-licensure physical therapists to enrich their ethical sensitivity. As a profession, we must demonstrate leadership and research to further advance moral dialogue in physical therapy. E. Lynne Geddes, PT, MRE, is Clinical Professor and Assistant Dean, Physiotherapy, School of Rehabilitation Science, Institute for Applied Health Sciences (Room 403), McMaster University, 1400 Main St West, Hamilton, Ontario, Canada L8S 1C7. Address all correspondence to Ms Geddes at: [email protected]. DOI: 10.2522/ptj.20090379.ic

References 1 Delany CM, Edwards I, Jensen GM, Skinner E. Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics. Phys Ther. 2010;90: 1068 –1078. 2 Swisher LL. A retrospective analysis of ethics knowledge in physical therapy (1970 – 2000). Phys Ther. 2002;82:692–706.

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3 Carpenter C, Richardson B. Ethics knowledge in physical therapy: a narrative review of the literature since 2000. Phys Ther Rev. 2008;13:366 –374. 4 Code of Ethics. College of Physiotherapists of Ontario. 2009. Available at: http:// www.collegept.org/Physiotherapists/ College%20Documents/Registrants% 20Guide/RegistrantsGuide. Accessed April 6, 2010. 5 Standards for Professional Ethics. College of Physiotherapists of Ontario. 2009. Available at: http://www.collegept.org/ Physiotherapists/College%20Documents/ Registrants%20Guide/RegistrantsGuide. Accessed April 6, 2010. 6 APTA Core Ethics Documents. 2010. Available at: http://www.apta.org/AM/Template. cfm?Section⫽Ethics_and_Legal_Issues1& Template⫽/CM/HTMLDisplay.cfm& ContentID⫽63868. Accessed April 6, 2010. 7 Swisher LL, Hiller P; the APTA Task Force to Revise the Core Ethics Documents. The revised APTA Code of Ethics for physical therapists and Standards of Ethical Conduct for the Physical Therapist Assistant: theory, purpose, process, and significance. Phys Ther. 2010;90:803– 824. 8 Carpenter C. Moral distress in physical therapy practice. Physiother Theory Pract. 2010;26:69 –78. 9 Nisker J. A covenant model for the medical educator-student relationship: lessons from the covenant model of the physicianpatient relationship. Med Educ. 2006;40: 502–503. 10 Walker LJ, Frimer JA. Moral personality of brave and caring exemplars. J Pers Soc Psychol. 2007;93:845– 860. 11 Rest JR. Background: theory and research. In: Rest JR, Narva´ez D, eds. Moral Development in the Professions: Applied Psychology and Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1994:1–26. 12 Nordgren A. Ethics and imagination. Theor Med Bioeth. 1998;19:117–141. 13 Lachman VD. Moral courage: a virtue in need of development. Medsurg Nurs. 2007;16:131–133. 14 Weaver K, Morse J, Mitchman C. Ethical sensitivity in professional practice: concept analysis. J Adv Nurs. 2008;62: 607– 618. 15 Nisker J, ed. From the Other Side of the Fence: Stories From Health Care Professionals. Lawrencetown Beach, Nova Scotia, Canada: Pottersfield Press; 2008. 16 Guillemin M, McDoucgall R, Gillam L. Developing “ethical mindfulness” in continuing professional development in healthcare: use of a personal narrative approach. Camb Q Healthc Ethics. 2009;18:197–208. 17 Wainwright SF, Shepard KF, Harman LB, Stephens J. Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Phys Ther. 2010;90:75– 88. 18 Nortvedt P. Clinical sensitivity: the inseparability of ethical perceptiveness and clinical knowledge. Sch Inq Nurs Pract. 2001;15:25– 43.

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Author Response Geddes identifies some highly relevant points in her commentary1 about the ethics engagement model.2 In particular, she highlights how everyday clinical practice for physical therapists is increasingly complex and professional accountability and autonomy are expanding in line with expanded scope of practice. As a response to this clinical and ethical environment, Geddes suggests that the ethics engagement model distills the more complex or detailed models of ethical decision making into 3 simple components and presupposes a sound understanding of ethics by the practitioner. This is an important comment that requires clarification and elaboration. In developing the 3 steps of the model, our intention was not to distill complex steps of gathering information: identifying ethical issues; using ethical theories and principles, and identifying and evaluating actions.3 Instead, the goal was to illuminate the ethical moments within the myriad of tasks, communication encounters, and relationship negotiations that occur in everyday clinical practice. Through this illumination and immersion in the details of everyday clinical moments, the 3 steps and their accompanying questions were developed to facilitate deeper connections with, and perhaps new and more sound ways of understanding and responding to, the ethical dimensions of clinical practice. The questions were designed to stimulate moral imagination and sensitivity and, as a consequence, provide practical options for the physical therapist to act ethically and courageously. For example, answering the questions in the active listening step means having to think about the patient from the patient’s perspective. Attending to the reflexive questions July 2010

Clare M. Delany, Ian Edwards, Gail M. Jensen, Elizabeth Skinner in step 2 necessarily increases awareness of one’s own personal and professional values and attitudes. Being prompted to think of broader influences beyond the patient/therapist relationship via the critical thinking questions increases the understanding of the cultural, political, institutional, and economic factors that affect ethical decisions and the capacity, motivation, and opportunity to make them. Geddes correctly identifies that the model does not explicitly refer to a course of action. We have purposefully taken the stance that highlighting what a therapist ought to do does not necessarily imply that a therapist can do. The clinical circumstances including personal motivation, practical opportunity, and level of experience4,5 can all affect ethical actions and responses. Using the theoretical background of narrative and reflective theory, telling and listening to clinical stories, reactions, thoughts, and feelings combined with enquiring about social processes and hierarchies is a powerful way to “develop clarity, insight and therefore understanding of an appropriate course of action.”6(p205) The thinking steps in the active engagement model, therefore, are designed to open up a range of ways to understand and to respect each therapist’s ability to think for himself or herself and to recognize and harness his or her own moral agency. The questions guide therapists or students to examine, with sensitivity and with imagination, hidden values and perspectives that they and others bring to the clinical encounter. An important assumption in developing this model is that ethical sensitivity does not automatically emerge as a consequence of reading a professional code of ethics. Writing about

educational approaches to teaching “habits of the mind,” Tishman suggested that teaching sensitivity involves “teaching students to notice occasions when it is appropriate to ask questions rather than pointing out occasions to use them.”7(p47) From the same premise of facilitating ethical thinking “habits of the mind,” the questions in the ethics engagement model are integral to its purpose, and not, as Geddes suggests, an adjunct to the model. They aim to provide a practical means to bridge the gap between normative ethical principles and empirical realities of practice.8 The active engagement model aims to underpin and, therefore, strengthen the steps in traditional models of ethical decision making. Geddes’ comments are incisive because they illuminate an important and sometimes hidden aspect of ethics education. Although students and practitioners can be instructed as to their ethical obligations using a range of models and educational approaches, unless they have the sensitivity to recognize an ethical issue in practice, the imagination to understand different perspectives and experiences, and the motivation and courage to act, knowledge of ethical obligations and ethical theory is unlikely to be achieve its aims. Different approaches to ethics education represent particular understandings of what is important in terms of ethical practice and what sorts of knowledge, skills, and attitudes students need to acquire during their education in order to be ethically competent practitioners.9 For example, the most established trend in ethics education is to teach ethical practice as a process of ethical decision making.10 In this approach, skills of critical thinking and

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Ethics Knowledge and Practice in Physical Therapy analysis are combined with knowledge of ethical theories and principles. Virtue ethics is a second approach, and it emphasizes the development of personal qualities, including the promotion of a caring attitude.11 Advocacy is a third approach to ethics in clinical practice. It promotes the ethical role of the health care professional to protect and promote the rights of the patient.12 Ethics as a form of moral agency and as a form of professional identity represents the fourth and fifth strands evident in health care professional ethics education. These strands emphasize the need for professionals to be aware of and to explore the ethical responsibilities that arise from having independent moral agency and professional identity in particular clinical contexts. Common to each of these trends or approaches to ethics education is the need for moral sensitivity, imagination, and courage. Although, as Geddes suggests, the model is conceptually dense and is underpinned by complex theory, the questions to facilitate the thinking within each step are designed to provide a scaffold for the development of the cru-

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cial attitudes of sensitivity and imagination in students and practitioners. “Scaffolding” is widely used in education and clinical learning as a means to encourage and enable students to develop independent skills and attitudes.13 In this way, the model provides an essential underpinning for many of the approaches and models of ethics education and ethical decision making. DOI: 10.2522/ptj.20090379.ar

References 1 Geddes EL. Invited commentary on “Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics.” Phys Ther. 2010;90:1078 –1080. 2 Delany CM, Edwards I, Jensen GM, Skinner E. Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics. Phys Ther. 2010;90:1068 – 1078. 3 Purtilo RB. Ethical Dimensions in the Health Professions. 4th ed. Philadelphia, PA: Elsevier Saunders; 2005. 4 Jensen GM, Paschal K. Habits of mind: student transition toward virtuous practice. J Phys Ther Educ. 2000;14(3):42– 47. 5 Jensen GM. Mindfulness: applications for teaching and learning in ethics education. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005: 191–202.

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6 Bolton G. Narrative writing: reflective enquiry into professional practice. Educational Action Research. 2006;14:203–218. 7 Tishman S. Why teach habits of mind? In: Costa AL, Kallick B, eds. Discovering and Exploring Habits of Mind. Alexandria, VA: Association for Supervision and Curriculum Development; 2000:41–52. 8 Schleidgen S, Jungert M, Bauer R. Mission: Impossible? On empirical-normative collaboration in ethical reasoning. Ethical Theory & Moral Practice. 2010;13(1):59 – 71. 9 Delany CM, Gillam L, Mcdougall R. Ethics in clinical education. In: Delany CM, Molloy L, eds. Clinical Education in the Health Professions. Philadelphia, PA: Elsevier Saunders; 2009. 10 Edwards I, Delany CM. Ethical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. 3rd ed. Boston, MA: Elsevier; 2008:279 –289. 11 Oakley J. A virtue ethics approach. In: Kuhse H, Singer P, eds. A Companion to Bioethics. 2nd ed. Oxford, United Kingdom: Blackwell; 2001. 12 Nelson L. Professional responsibility and advocacy for access to rehabiltation services: a case study in lymphedema services in Vermont. In: Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis Co; 2005. 13 Vygotsky L. Mind in Society: The Development of the Highter Psychological Processes. Cambridge, MA: Harvard University Press; 1978.

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Letters to the Editor On “Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease.” Coronado RA, et al. Phys Ther. 2010;90:784–792. First, I would like to commend the authors on describing a wellthought-out diagnostic approach when examining a patient with complex low back pain (LBP).1 I believe this article clearly shows how difficult the diagnostic process can be in patients with LBP. A critical question brought up by the authors of this case report is: should we move away from identifying specific tissue pathology or pain generators when trying to make a diagnosis in patients with LBP? I think this article gives us a clear reason why we should probably not. Although definitely not perfect (what method is?), identifying potential generators of LBP gives us an inductive and deductive method that can determine where the pain is likely or is not likely coming from. In this case, provocation tests were used to help rule out the hip as well as to suggest the sacroiliac joint as a likely reason for the patient’s LBP. The problem with pain provocation is that—although it may help identify where the pain comes from—often it cannot guide or direct treatment. I believe this case report demonstrated that well by showing that the clinical course, where the patient exhibited a successful reduction in her pain after demonstrating a directional preference position, was the key to the diagnosis of her LBP. This case report clearly illustrates that we often need to use more than one method when trying to find the most accurate diagnosis for our patients.

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After reading about all of the diagnostic workup on this patient, I was left confused as to why the sacroiliac joint was not considered the primary cause. Why was spondyloarthritis considered the more likely reason? Isn’t this just an example of Occam’s razor, where only one diagnosis could explain this patient’s problem? Or did the authors really believe that Hickam’s dictum was at work here, where 2 separate diagnoses (sacroiliitis and spondyloarthritis) were both likely reasons for the symptoms? If so, I was left unclear as to how the 2 different diagnoses were disentangled. This is a common dilemma that we often face. I would appreciate hearing the authors’ thoughts on this. Finally, the diagnostic confusion led me to my next question: Is there really a difference between mechanical and inflammatory LBP? To me, this is a seminal concept in our understanding of the nature of LBP. I have always assumed and still teach that LBP, like any other inflammatory problem, comes from the chemical/inflammatory mediators and the local swelling derived from the inflammatory process within the structures and tissues of the lower back. Can LBP come from mechanical irritation without the mediation of the inflammatory response? I doubt this is so in most cases; however, I think this makes for an interesting debate. Michael T. Cibulka M.T. Cibulka, PT, DPT, MHS, OCS, is Assistant Professor, Maryville University, St Louis, MO. This letter was posted as a Rapid Response on May 28, 2010, at ptjournal.apta.org.

Reference 1 Coronado RA, Sheets CZ, Cook CE, Boissonnault WG. Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease. Phys Ther. 2010;90:784–792. [DOI: 10.2522/ptj.2010.90.7.1083.1]

Author Response We appreciate the response letter written by Dr Cibulka1 on our recent case report.2 We are in complete agreement with the points raised regarding the common limitations of low back pain (LBP) diagnosis and the need for a thorough and logical clinical examination sequence. Although our case did not explicitly state a specific sacroiliac joint (SIJ) diagnosis, it is clear to us that, based on the key findings of the examination (namely the lack of centralization and the positive response to SIJ stress tests)3 and the initial choice of treatment (ostensibly directed at the SIJ),4–6 the anatomic region suspected as contributing to the patient’s symptoms was the SIJ. There is current debate in the physical therapy literature about how confident we can be in determining a specific pathoanatomic diagnosis and whether this has clinical value. As such, we refrained from making such a diagnosis in this paper. We cannot dispute Cibulka’s comments that this case identified one of the relatively few patients in whom a pathoanatomic diagnosis could be confidently inferred from clinical findings, especially when the diagnosis was supported by diagnostic imaging. Some confusion may lie in the use of the terms sacroiliitis and spondyloarthritis. Cibulka implies that the two are separate entities. However, as our case mentions, symptoms consistent with sac-

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Scholarships, Fellowships, and Grants News from the Foundation for Physical Therapy Recent Publications by Foundation-Funded Researchers “Femur Rotation and Patellofemoral Joint Kinematics: A WeightBearing Magnetic Resonance Imaging Analysis,” by Souza RB, Draper CE, Fredericson M, and Powers CM, was published in the Journal of Orthopaedic & Sports Physical Therapy (2010;40[5]:277– 285). Richard Souza, PT, MPT, received a 2004 Promotion of Doctoral Studies (PODS) I scholarship, a 2006 PODS II, and a 2007 PODS II. Christopher Powers, PT, PhD, received a 2001 Research Grant. “Anxiety and Stress Can Predict Pain Perception Following a Cognitive Stress,” by Bement MH, Weyer A, Keller M, Harkins A, and Hunter S, was published online in Physiology & Behavior on April 29, 2010. Marie Hoeger Bement, PT, PhD, received a 2000 Kendall Doctoral Scholarship. “A Randomized Clinical Trial of the Effectiveness of Mechanical Traction for Sub-Groups of Patients With Low Back Pain: Study Methods and Rationale,” by Fritz JM, Thackeray A, Childs JD, and Brennan GP, was published online in BMC Musculoskeletal Disorders on April 30, 2010. Julie Fritz, PT, PhD, ATC, received a 2002 Orthopaedic Section Endowment Research Grant. John Childs, PT, PhD, MBA, won a 2001 PODS I and a 2004 Research Grant. “Self-Management of Rheumatic Diseases: State of the Art and Future Perspectives,” by Iversen MD, Hammond A, and Betteridge N, was published online in the Annals of the Rheumatic Diseases on May 6, 2010. Maura Iversen, PT, DPT, ScD, MPH, won a 2000 Research Grant. July 2010

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“Non-Paretic Quadriceps Activity Influences Paretic Quadriceps Activity Post-Stroke,” by Lewek MD, Breslin R, Hlad L, Lanton A, and St John J, was published online in Clinical Neurophysiology on May 5, 2010. Michael Lewek, PT, PhD, received a 2002 PODS II and a 2009 Geriatric Research Grant. “Relationships Between Maximum Holding Time and Ratings of Pain and Exertion Differ for Static and Dynamic Tasks,” by Frey Law LA, Lee JE, McMullen TR, and Xia T, was published online in Applied Ergonomics on May 10, 2010. Laura Frey Law, PhD, MPT, MS, won a 2000 Kendall Doctoral Scholarship, a 2001 PODS I, and a 2002 PODS II.

1999 Kendall Doctoral Scholarship and a 2001 PODS.

Congratulations to the Latest PODS I & II Recipients Promotion of Doctoral Studies (PODS) I scholarships of up to $7,500 are awarded to outstanding physical therapists or physical therapist assistants who have completed at least 2 full semesters or 3 full quarters of their coursework toward a doctorate degree. PODS II scholarships of up to $15,000 each are awarded to physical therapists or physical therapist assistants who have been formally admitted to doctoral candidacy. The 2010 PODS I awardees are: •

Meryl Alappattu, PT, DPT

“Parent and Therapist Perceptions of an Intense Model of Physical Therapy,” by Christy JB, Saleem N, Turner PH, and Wilson J, was published in Pediatric Physical Therapy (2010;22[2]:207–213). Jennifer Christy, PT, PhD, won a 2001 Kendall Doctoral Scholarship, a 2002 PODS I, and a 2003 Pediatric Section Research Grant.

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Eric Anson, PT, MPT

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Michael Bade, PT, MPT

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Amy Feldman Bailes, PT, MS, PCS

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Jennifer Hide, PT, DPT

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Virginia Little, PT, MS, NCS

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David Logerstedt, PT, MPT, MA

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Ericka Merriwether, PT, DPT

“Endurance Training and Cardiorespiratory Conditioning After Traumatic Brain Injury,” by Mossberg KA, Amonette WE, and Masel BE, was published in the Journal of Head Trauma Rehabilitation (2010;25[3]:173–183). Kurt Mossberg, PT, PhD, won a 1985 Foundation Grant.

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Barbara Sargent, PT, MS, PCS

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Jaclyn Sions, PT, DPT, OCS

“Balance, Attention, and DualTask Performance During Walking After Brain Injury: Associations With Falls History,” by McCulloch KL, Buxton E, Hackney J, and Lowers S, was published in the Journal of Head Trauma Rehabilitation. (2010;25[3]:155–163). Karen McCulloch, PT, PhD, NCS, won a

The 2010 PODS II awardees are: •

Keith Avin, PT, DPT

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Stacey DeJong, PT, MPT, MS

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Jonathan Dropkin, PT, MS

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Bernadette Gillick, PT, MS

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Manda Keller, PT, DPT

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Mark Lyle, PT, MSPT, OCS

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Lynnette Montgomery, PT, BPhty

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William Thompson, PT, DPT

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Lori Tuttle, PT, MPT

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Richard Willy, PT, MPT

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Melissa Wright, PT, MPT

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Scholarships, Fellowships, and Grants

Congratulations to the 2010 Split Raffle Winners

Current Funding Opportunities

The Foundation for Physical Therapy had another successful year, raising $130,000 through the Split Raffle, which supports funding opportunities awarded to outstanding physical therapist researchers. Thank you to all contributors who purchased full or partial tickets.

The Foundation is now accepting applications for the Kendall Scholarship and Research Grant programs! Students beginning their doctoral programs are encouraged to apply to win one of the $5,000 Kendall Scholarships. The Foundation also awards $40,000 Research Grants to emerging investigators to assist them in establishing a track record of funding. Applications for both funding opportunities are due August 18 at noon, ET. For more details, please visit the Foundation’s Web site at www. FoundationforPhysicalTherapy. org and click on “Grants, Fellowships & Scholarships.”

Grants and scholarships awarded by the Foundation are made possible through the generosity of our donors. There are many ways you can support the Foundation—here are just a few:

Do You Have News You Would Like to Share?

Please consider helping us to secure the future of physical therapy research. Visit our Web site at www. FoundationforPhysicalTherapy.org, email us at [email protected], or call 800/875-1378.

Winners of the $10,000 grand prize were: Michael Fortanasce, PT, DPT, David Gutkind, PT, DPT, OCS, Lilian Chen, PT, DPT, OCS, and Kenneth Mengel, PT, MPT, OCS. Winners of the $2,000 prizes were: Catherine Lane, PT, DPT, MS, Louise Yurko, PT, MAEd, Judy Hershberg, PT, DPT, MS, Jean-Pierre Viel, PT, DPT, OCS, Dennis Spillane, PT, MBA, Ann Grove, PT, Constance Carlson, PT, R. Scott Ward, PT, PhD, Duane Fast, Kevin Hulsey, PT, DPT, Elena Wahbeh, PT, Bette Horstman, PT, Clara Bright, PT, Carolyn Bloom, PT, Illinois Chapter of APTA, Robert Burger, PT, MSPT, Gary Clark, PT, Mary Lee Beach, PT, MS, OCS, University of Wisconsin–Madison PT Program.

If you would like to include any announcements in the Foundation’s section, contact our communications assistant Abegail Matienzo at [email protected].

Support the Next Generation of Researchers

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Make a gift online at www. FoundationforPhysicalTherapy. org.

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Sign up to make a monthly gift through our ExcePTional program.

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When paying your APTA dues, check the box to donate to the Foundation.

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Make a gift in honor of a special person, a milestone, or an event.

[DOI: 10.2522/ptj.2010.90.7.1087]

Special thanks to this year’s volunteers: Carolyn Bloom, PT, Robert Deusinger, PT, PhD, Susan Deusinger, PT, PhD, FAPTA, Melanie Gillar, PT, DPT, MA, Connie Hauser, PT, DPT, ATC, Chuck Martin, CAE CIA, Timothy Schell, PT, Brad Thuringer, PTA, and Louise Yurko, PT, MAEd.

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